Joint Commission

International Accreditation
Standards for

Hospitals
Including Standards for Academic Medical Center Hospitals
8th Edition | Effective 1 January 2025
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“Global Health Impact” (GHI) chapter only: © 2024 The Joint Commission on behalf of
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Development Team for the 8th Edition

Director, Standards Development and Interpretation: Associate Director, Standards Development
Ron Quicho, MS, MBA and Interpretation: Victoria Nalezny, MS,
Associate Director, Standards Development OTR/L, CSRS
and Interpretation: Laura Evans, MS, Associate Director, Production: Johanna Harris
RN Executive Director, Global Publishing:
Associate Director, Standards Development and Catherine Chopp Hinckley, MA, PhD
Interpretation: Antigone E. Kokalias, MBA, MSN, Associate Director, Editorial, Accreditation Content:
RN
Mary Beth Curran
Technical Advisory Panel for the 8th Edition
Dave Allegaert
Patricia O’Shea, MD, MPH, MBA
Manager
Surveyor
kwaliteit & innovatie
Joint Commission International
Belgium
USA
Yvonne P. Burdick, MHA, FACHE,
Babak Pazooki, MD, MS, FACE, CPHQ
EDAC Consultant
Surveyor
Joint Commission International
Joint Commission International
USA
USA
Chinhak Chun, MD
Thomas Schaefer, DDS,
Consultant
MS Surveyor
Joint Commission International
Joint Commission International
USA
USA
Haroon Hafeez, FRCP, FRCPE
Smadar Sharbi RN, MPA
Consultant Physician Internal/Palliative Medicine
Director of Quality and Accreditation,
Director, Quality and Patient Safety
Division of Government Medical Centers
Department SKMCH & RC
Israel Ministry of Health
Pakistan
Israel
Paul Hofmann, DrPH, LFACHE
Renee Thompson, DNP, RN, FAAN
President
CEO and Founder
Hofmann Healthcare Group
Healthy Workforce Institute
USA
USA
James Kendig, MS, CHSP, HEM
Shin Ushiro, MD, PhD
Field Director, Surveyor
Professor and Director, Division of Patient Safety
Management
Kyushu University Hospital
and Development
Japan
The Joint Commission
USA Özlem Yıldırım Veenstra, PhD, BSIE, MSEM
Surveyor
Eve Lai
Joint Commission International
Performance Improvement/Risk Manager
USA
Hong Kong Adventist Hospital
Hong Kong Bryan Warren, MBA, CHPA, CPO-
I President
Rinat Megreleshvili, RN, MN
WarSec
Director, Department of Hospital
Security USA
Accreditation Clalit Health Services
Israel Ann Watkins, BNS, MEd
Surveyor
Shaik Mohiuddin
Joint Commission International
Chief Quality Officer
USA
SEHA Abu Dhabi
United Arab Emirates

iii
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

iv
 Contents

Summary of Changes to the Manual.............................................................................vii

Introduction.....................................................................................................................1
The Value of JCI Accreditation............................................................................1
Standards Development Process...........................................................................2
How This Manual Is Organized...........................................................................3
Applying the Standards in Your Organization.......................................................5
Using the Standards Manual.................................................................................6
General Eligibility Requirements..........................................................................7
Section I: Accreditation Participation Requirements...................................................9
Accreditation Participation Requirements (APR)................................................11
Section II: Patient-Centered Standards......................................................................19
Access to Care and Continuity of Care (ACC)..................................................21
Assessment of Patients (AOP).............................................................................41
Anesthesia and Surgical Care (ASC)...................................................................71
Care of Patients (COP).......................................................................................85
International Patient Safety Goals (IPSG).........................................................109
Medication Management and Use (MMU).......................................................123
Patient-Centered Care (PCC)...........................................................................149
Section III: Health Care Organization Management Standards.............................165
Facility Management and Safety (FMS)............................................................167
Governance, Leadership, and Direction (GLD)................................................193
Health Care Technology (HCT)........................................................................217
Management of Information (MOI).................................................................231
Prevention and Control of Infections (PCI).....................................................245
Quality and Patient Safety (QPS).....................................................................271
Staff Qualifications and Education (SQE)........................................................283
Section IV: Global Health Impact Standards...........................................................317
Global Health Impact (GHI)............................................................................319

Section V: Academic Medical Center Standards.......................................................327

v
Human Subjects Research Programs (HRP)......................................................329
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION
Medical Professional Education (MPE).............................................................337
Appendix....................................................................................................................345
Interim Measures.............................................................................................347
Patient Safety Systems (PS)...............................................................................349
Sentinel Event Policy (SE)................................................................................363
Summary of Key Accreditation Policies.......................................................................373
Glossary......................................................................................................................383
Index...........................................................................................................................409

vi
 Summary of Changes
to the Manual

Accreditation Participation Requirements (APR)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
APR.01.00 APR.1 ME 1 was added as scorable requirement on timely
X
submission of data and information to JCI.
APR.02.00 APR.2 ME 1 was added as scorable requirement on providing
accurate information throughout the accreditation X
process.
APR.03.00 APR.3 ME 1 was added as scorable requirement on
informing JCI of any organization changes through X
organization’s E-App.
APR.04.00 APR.4 ME 1 was added as scorable requirement on perfor-
X
mance of JCI surveys.
APR.05.00 APR.5 ME 1 was added as scorable requirement on providing
X
JCI official records and reports when requested.
APR.06.00 APR.7 Renumbered requirement and added ME 1 as
X
scorable element focused on performance measures.
APR.07.00 APR.8 Renumbered requirement with two scorable measur-
able elements focused on accurate advertising of JCI X
accreditation.
APR.08.00 APR.9 Renumbered requirement with three scorable mea-
surable elements focused on staff reporting safety or X
quality concerns without retribution.
APR.09.00 APR.11 Renumbered requirement with two measurable mea-
surable elements focused on informing public on X
how to report concerns on patient safety and quality
of care.
APR.10.00 APR.10 ME 1 was added as scorable requirement on providing
X
qualified translator when applicable.
APR.11.00 APR.12 ME 1 was added as scorable requirement on providing
X
safe environment.

vii
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

Access to Care and Continuity of Care (ACC)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
ACC.01.00 ACC.1 Renumbered standard with six measurable elements
similar to the 7th Edition.
ACC.01.01 ACC.1 Renumbered standard with five measurable elements
focused on patients with emergent, urgent, and
immediate needs.
ACC.01.02 ACC.1.1 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
ACC.02.00 ACC.2 Renumbered standard now with four measurable
elements focused on patient flow processes.
ACC.02.01 ACC.2.2 Renumbered standard with six measurable elements
focused on patient education.
Moved PCC.4, ME 1 (7th Edition) to ACC.02.01,
ME 4 (8th Edition).
Moved PCC.4, ME 2 (7th Edition) to ACC.02.01,
ME 5 (8th Edition).
Moved PCC.4, ME 4 (7th Edition) to ACC.02.01,
ME 6 (8th Edition).
ACC.02.02 ACC.2.3 Renumbered standard with four measurable elements
focused on criteria for specialized units/departments.
ACC.03.00 ACC.3 Renumbered standard with six measurable elements
similar to the 7th Edition.
ACC.03.01 ACC.3.1 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
ACC.04.00 ACC.4 Renumbered standard with six measurable elements
similar to the 7th Edition.
ACC.04.01 ACC.4.1 Renumbered standard with five measurable elements
focused on patient/family discharge education.
ACC.04.02 ACC.4.2 Renumbered standard with five measurable elements
similar to the 7th Edition.
ACC.04.03 ACC.4.2.1 Renumbered standard with four measurable elements
similar to the 7th Edition.
ACC.04.04 ACC.4.3 Renumbered standard with four measurable elements
similar to the 7th Edition.
ACC.04.05 ACC.4.4 Combined into one standard with six measurable
ACC.4.4.1 elements focused on leaving against medical advice.
ACC.05.00 ACC.5 Renumbered standard with six measurable elements
similar to the 7th Edition.
ACC.05.01 ACC.5.1 Renumbered standard with two measurable elements
focused on transfer documentation.
ACC.06.00 ACC.6 Renumbered standard with six measurable elements
focused on transportation services.

viii
 SUMMARY OF CHANGES TO THE
MANUAL

Assessment of Patients (AOP)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
AOP.01.00 AOP.1 Renumbered standard with four measurable elements
similar to the 7th Edition.
AOP.01.01 AOP.1.1 Combined into one standard with nine measurable
AOP.1.2 elements focused on the initial assessment.
AOP.1.2.1 ME 3 focuses on requirements of the initial
X
assessment.
ME 4 focuses on special populations that
X
require assessment modifications.
AOP.01.02 AOP.1.3 Renumbered standard with three measurable ele-
ments focused on outside source assessments.
AOP.01.03 AOP.1.4 Renumbered standard with five measurable elements
focused on screening for nutritional, functional, or
other special needs.
AOP.01.04 AOP.1.5 Renumbered standard with five measurable elements
focused on pain assessment.
AOP.01.05 AOP.2 Renumbered standard with four measurable elements
focused on reassessment intervals.
AOP.02.00 IPSG.6 Renumbered standard moved from IPSG
IPSG.6.1 chapter with four measurable elements focused
on fall risk.
AOP.03.00 AOP.5 Renumbered standard with three measurable ele-
ments focused on laboratory services.
AOP.03.01 AOP.5.1 Renumbered standard with five measurable elements
similar to the 7th Edition.
AOP.03.02 AOP.5.2 Renumbered standard with five measurable elements
similar to the 7th Edition.
AOP.03.03 AOP.5.4 Renumbered standard with four measurable elements
focused on reporting of lab results.
ME 4 focuses on corrective action when lab
X
results are not reported correctly.
AOP.03.04 AOP.5.5 Renumbered standard with five measurable elements
similar to the 7th Edition.
AOP.03.05 AOP.5.6 Renumbered standard with five measurable elements
focused on reagents and supplies for laboratory
services.
ME 5 focuses on the information required for
X
reagent records.
AOP.03.06 AOP.5.7 Renumbered standard with six measurable elements
similar to the 7th Edition.
AOP.03.07 AOP.5.8 Renumbered standard with five measurable elements
similar to the 7th Edition.

ix
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
AOP.03.08 AOP.5.9 Combined into one standard with six measurable
AOP.5.9.1 ele- ments focused on laboratory service quality
control and proficiency testing.
AOP.03.09 AOP.5.10 Combined into one standard with five measurable
AOP.5.10.1 elements focused on services provided by contracted
laboratories.
AOP.04.00 AOP.5.11 Renumbered standard with six measurable elements
focused on blood bank and transfusion services.
ME 5 focuses on monitoring and improving
X
utilization.
ME 6 focuses on hemovigilance surveillance. X
AOP.04.01 COP.3.4 New standard with five measurable elements focused
on clinical guidelines for administration of blood X
and blood products.
AOP.05.00 AOP.6 Renumbered standard with four measurable elements
similar to the 7th Edition.
AOP.05.01 AOP.6.1 Renumbered standard with six measurable elements
similar to the 7th Edition.
AOP.05.02 AOP.6.2 Renumbered standard with seven measurable
elements focused on radiation and/or
diagnostic imaging safety.
ME 6 focuses on the individual serving as the
X
radia- tion safety officer.
AOP.05.03 AOP.6.3 Renumbered standard with four measurable elements
focused on radiology and diagnostic imaging results.
ME 4 focuses on corrective action when results
X
are not reported in the expected time frame.
AOP.05.04 AOP.6.4 Renumbered standard with five measurable elements
similar to the 7th Edition.
AOP.05.05 AOP.6.5 Renumbered standard with three measurable ele-
ments focused on quality control for radiology and
diagnostic imaging services.
AOP.05.06 AOP.6.6 Renumbered standard with five measurable elements
focused on contracted services.
MEs 1 and 2 focus on maintaining a copy of licenses
X
and certificates from a recognized authority.
AOP.06.00 N/A New standard with five measurable elements
X
focused on nuclear medicine safety.

x
 SUMMARY OF CHANGES TO THE
MANUAL

Anesthesia and Surgical Care (ASC)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
ASC.01.00 ASC.1 Combined into one standard with six
ASC.2 measurable elements focused on the provision of
sedation and anesthesia services.
ASC.02.00 ASC.3 Renumbered standard with two measurable elements
similar to the 7th Edition.
ASC.02.01 ASC.3.1 Renumbered standard with three measurable elements
focused on the qualifications of practitioners and
staff responsible for procedural sedation.
ASC.02.02 ASC.3.2 Renumbered standard with five measurable elements
focused on the administration, monitoring, and
documentation of procedural sedation according to
professional practice guidelines.
ME 4 focuses on the presedation
assessment performed by a qualified X
individual and the documentation.
ASC.02.03 ASC.3.3 Renumbered standard with three measurable elements
similar to the 7th Edition.
ASC.03.00 ASC.4 Renumbered standard with four measurable ele-
ments focused on the preanesthesia and preinduction
assessments.
ME 4 focuses on the scope and content of the
X
prean- esthesia and preinduction assessment.
ASC.03.01 ASC.5 Renumbered standard with six measurable elements
focused on discussing the anesthesia plan of care
with the patient and/or decision-maker.
ME 6 focuses on anesthesia care according to profes-
X
sional practice guidelines and hospital policy.
ASC.03.02 ASC.6 Renumbered standard with three measurable elements
similar to the 7th Edition.
ASC.03.03 ASC.6.1 Renumbered standard with four measurable elements
similar to the 7th Edition.
ASC.04.00 ASC.7 Renumbered standard with four measurable elements
AOP.1.3.1 focused on the preoperative assessment.
Moved documentation requirement from
AOP.1.3.1, ME 3 (7th Edition) to ASC.04.00, ME X
1 (8th Edition).
Moved Standard AOP.1.3.1 (7th Edition) to
X
ASC.04.00, ME 2 (8th Edition).

xi
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
ASC.04.01 ASC.7.1 Renumbered standard with two measurable
elements focused on risks, benefits, and alternatives
of surgical procedures.
Moved ASC.7.1, ME 2 (7th Edition) to ASC.04.01,
ME 1 (8th Edition).
ASC.04.02 ASC.7.2 Renumbered standard with three measurable elements
similar to the 7th Edition.
ASC.04.03 ASC.7.3 Renumbered standard with four measurable elements
similar to the 7th Edition.
ASC.04.04 ASC.7.4 Renumbered standard with five measurable elements
focused on planning surgical care that includes
implantable devices.
ME 3 focuses on the information the patient
X
receives on the implantable device.

Care of Patients (COP)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
COP.01.00 COP.2 Renumbered standard with six measurable
IPSG.2 elements focused on prescribing, documenting,
and carrying out orders; and reporting results.
ME 3 moved from IPSG.2 (7th Edition). X
ME 6 moved from IPSG.2 (7th Edition). X
COP.01.01 COP.2.2 Renumbered standard with four measurable elements
focused on individualized patient care plans.
COP.01.02 COP.3 Renumbered standard with five measurable elements
similar to the 7th Edition.
COP.02.00 COP.3.1 Renumbered standard with six measurable elements
focused on clinical alarm safety.
ME 6 focuses on performance improvement efforts
X
for clinical alarm safety.
COP.03.00 COP.3.2 Renumbered standard with four measurable elements
similar to the 7th Edition.
COP.04.00 COP.3.3 Renumbered standard with four measurable elements
similar to the 7th Edition.
ME 4 focuses on expanded requirements for perfor-
mance improvement related to resuscitation.

xii
 SUMMARY OF CHANGES TO THE
MANUAL

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
COP.05.00 COP.3.5 Renumbered standard with seven measurable ele-
ments focused on care of suicidal patients.
ME 4 focuses on documentation of suicide screen-
X
ings and assessments.
ME 5 focuses on policies and procedures for staff
X
competence and reassessment of patients.
ME 6 focuses on follow-up care at discharge. X
COP.06.00 COP.5 Combined into one standard with eight measurable
COP.5.1 elements focused on delivery of nutrition services
and nutrition therapy.
COP.07.00 COP.6 Renumbered standard with four measurable elements
PCC.2.2 similar to the 7th Edition; includes duplicative con-
tent from PCC.2.2.
COP.08.00 COP.7 Renumbered standard with six measurable elements
PCC.2.2 similar to the 7th Edition.
COP.09.00 PCC.6 Moved and renumbered standard with four measur-
able elements focused on informing patients/families
about organ donation.
COP.09.01 PCC.6.1 Moved and renumbered standard with four measur-
able elements focused on provision of oversight of
organ and tissue procurement program.
COP.09.02 COP.8 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
COP.09.03 COP.8.1 Combined into one standard with seven measurable
COP.8.2 elements focused on qualified program leadership
and interdisciplinary team with expertise in relevant
transplant programs.
COP.09.04 COP.8.3 Renumbered standard with four measurable elements
similar to the 7th Edition.
COP.09.05 N/A New standard with seven measurable elements
focused on organ, tissue, and cell transplant
program responsibilities to include sharing of X
transplant data required by laws and regulations;
and receipt, trans- port, handling, and storage of
organs and tissues.
COP.09.06 COP.8.5 Renumbered standard with five measurable elements
similar to the 7th Edition.
COP.09.07 COP.8.6 Renumbered standard with five measurable elements
similar to the 7th Edition.

xiii
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
COP.09.08 COP.8.7 Renumbered standard with six measurable elements
focused on clinical practice guidelines and clinical
criteria guiding selection of organ and tissue trans-
plant recipients; standard language changed from
7th Edition.
ME 6 focuses on documentation of organ compati-
X
bility in patient records.
COP.10.00 COP.9 Renumbered standard with five measurable elements
similar to the 7th Edition.
COP.10.01 COP.9.1 Renumbered standard with four measurable elements
similar to the 7th Edition.
COP.10.02 COP.9.2 Renumbered standard with six measurable elements
similar to the 7th Edition.
COP.10.03 COP.9.3 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.

International Patient Safety Goals (IPSG)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
IPSG.01.00 IPSG.1 Renumbered standard with three measurable
ele- ments similar to the 7th Edition, with
expanded guidance for newborn naming
conventions.
IPSG.02.00 IPSG.2.1 Renumbered standard with four measurable elements
focused on critical results reporting.
IPSG.02.01 IPSG.2.2 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
IPSG.03.00 IPSG.3 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
IPSG.03.01 IPSG.3.1 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
ME 3 expanded to include review of list of
look- alike/sound-alike (LASA) medications
at least annually.
IPSG.03.02 IPSG.3.2 Renumbered standard with three measurable
elements focused on safe storage of concentrated
electrolytes.
ME 3 focuses on performing proactive risk assess-
ments at least annually where concentrated electro- X
lytes are stored.

xiv
 SUMMARY OF CHANGES TO THE
MANUAL

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
IPSG.04.00 IPSG.4 Renumbered standard with three measurable ele-
ments focused on preoperative verification and site
marking for safe surgery.
ME 1 expanded to include World Health
Organization (WHO) recommendations.
ME 4 expanded to include requirement for alterna-
tive site marking process.
IPSG.04.01 IPSG.4.1 Renumbered standard with four measurable elements
focused on time-out/Universal Protocol for safe
surgery.
ME 1 expanded to include WHO recommendations.
ME 4 new requirement to perform second time-
out for separate procedures performed by different X
indi- viduals during the same surgery episode.
IPSG.05.00 IPSG.5 Renumbered standard with three measurable ele-
ments similar to the 7th Edition; expanded require-
ment for ME 3 to collect and analyze data for hand
hygiene program.

Medication Management and Use (MMU)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
MMU.01.00 MMU.1 Renumbered standard with seven measurable ele-
ments focused on medication management processes.
ME 1 focuses on a qualified individual overseeing
X
the medication management team.
ME 3 focuses on members of the medication
X
manage- ment team.
MMU.01.01 MMU1.1 Renumbered standard with eight measurable elements
focused on antimicrobial stewardship.
ME 2 focuses on the antimicrobial stewardship
X
pro- gram interdisciplinary team.
ME 3 focuses on coordination of antimicrobial
X
use throughout the hospital.
ME 6 focuses on the program collecting, analyzing,
X
and reporting data.
ME 8 focuses on patient and family antimicrobial
X
education.

xv
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
MMU.01.02 MMU.3.2 Renumbered standard with six measurable elements
focused on a medication recall system process.
ME 3 focuses on labeling and isolating recalled
X
medication.
ME 4 focuses on notifying patients of recalled
X
medications.
ME 5 focuses on the process to inform health care
X
providers of medication recalls.
ME 6 focuses on the process for documenting
X
all actions related to medication recall.
MMU.01.03 N/A New standard with three measurable elements
X
focused on a process for handling expired
medications.
MMU.02.00 MMU.2 Renumbered standard with four measurable elements
focused on a process for the selection and procure-
ment of medications.
ME 1 focuses on interdisciplinary team collaboration
to determine criteria for medication selection and X
procurement.
MMU.03.00 MMU.3 Renumbered standard with six measurable elements
similar to the 7th Edition.
MMU.03.01 MMU.3.1 Renumbered standard with four measurable elements
similar to the 7th Edition.
MMU.04.00 MMU.4.1 Renumbered standard with two measurable elements
similar to the 7th Edition.
MMU.04.01 MMU.4.2 Renumbered standard with six measurable elements
focused on safe prescribing, ordering, and transcrib-
ing practices and elements of a complete order or
prescription.
ME 2 focuses on a diagnosis, condition, or
X
indication for use for each medication ordered.
ME 4 focuses on additional required elements
X
of complete medication orders or
prescriptions.
MMU.04.02 MMU.4 Renumbered standard with four measurable elements
focused on a medication reconciliation process.
ME 4 focuses on when medication review is
X
conducted.
MMU.05.00 MMU.5 Renumbered standard with six measurable elements
focused on medication preparation and dispensing
practices.
ME 4 focuses on visual inspection of medication. X

xvi
 SUMMARY OF CHANGES TO THE
MANUAL

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
MMU.05.01 N/A New requirements with five measurable
X
elements focused on a process for
radiopharmaceuticals.
MMU.05.02 MMU.5.1 Renumbered standard with seven measurable ele-
ments focused on medication appropriateness review.
ME 3 focuses on the process to conduct an appro-
priateness review for an order or prescription prior X
to dispensing.
ME 7 focuses on clarifying concerns, issues,
or questions with the provider prior to X
dispensing medication.
MMU.05.03 MMU.5.2 Renumbered standard with five measurable elements
focused on a medication dispensing system.
ME 4 focuses on requirements in a policy for
X
medica- tion labeling practices.
MMU.06.00 MMU.6 Combined into one standard with six measurable
MMU.6.1 elements focused on medication administration
per- formed by qualified individuals.
ME 6 focuses on administering a radioactive pharma-
X
ceutical for diagnostic purposes.
MMU.06.01 MMU.6.2 Combined into one standard with four measurable
MMU.6.2.1 elements focused on policies and procedures govern-
ing medication brought into the hospital, prescribed
for patient self-administration, and medication
samples.
ME 4 focuses on assessing the competence of the
X
patient or family administering medication.
MMU.07.00 MMU.7 Renumbered standard with seven measurable
ele- ments focused on actual or potential
adverse drug events and adverse drug reactions.
ME 2 focuses on a process to address prescriber noti-
X
fication for adverse drug events and reactions.
ME 6 focuses on conducting a root cause analysis of
data for adverse drug event patterns or undesirable X
trends.
MMU.07.01 MMU.7.1 Renumbered standard with five measurable elements
focused on a process for medication errors and near
miss events (or close calls).
ME 4 focuses on conducting a root cause analysis of
data for medication error and near miss patterns or X
undesirable trends.

xvii
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

Patient-Centered Care (PCC)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
PCC.01.00 PCC.1 Renumbered standard with six measurable elements
similar to the 7th Edition.
PCC.01.01 PCC.1.1 Combined into one standard with five measurable
PCC.1.2 elements focused on patients’ rights to access care,
have barriers removed, and have cultural and
religious preferences respected.
PCC.01.02 PCC1.3 Renumbered standard with five measurable elements
similar to the 7th Edition.
PCC.01.03 PCC.1.4 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
PCC.01.04 N/A New requirements with four measurable
X
elements focused on protection of vulnerable
populations.
PCC.02.00 PCC.2 Renumbered standard with four measurable elements
similar to the 7th Edition.
PCC.02.01 PCC.2.1 Renumbered standard with six measurable elements
similar to the 7th Edition.
PCC.02.02 PCC.3 Renumbered standard with four measurable elements
similar to the 7th Edition.
PCC.02.03 PCC.3.1 Renumbered standard with five measurable elements
focused on processes to manage patient complaints
and disclosure of clinical errors.
ME 3 focuses on content of a policy for disclosure of
X
clinical errors.
ME 4 focuses on implementation of a policy on
X
disclosure of clinical errors.
ME 5 focuses on a process to analyze and prevent the
X
error from recurring.
PCC.03.00 PCC.4 Combined into one standard with five
PCC.4.1 measurable elements focused on informed
PCC.4.2 consent policy and process for obtaining
PCC.4.3 informed consent.
PCC.4.4
PCC.04.00 PCC.5 Renumbered standard with four measurable elements
similar to the 7th Edition.
PCC.04.01 PCC.5.1 Combined into one standard with three
PCC.5.2 measurable elements focused on identification of
patient/family education needs and documentation
of education.

xvii
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 SUMMARY OF CHANGES TO THE
MANUAL

Facility Management and Safety (FMS)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
FMS.01.00 FMS.1 Renumbered standard with four measurable elements
focused on leadership and planning for facility use.
FMS.01.01 FMS.2 Renumbered standard with three measurable ele-
ments focused on oversight of the FMS structure.
FMS.02.00 FMS.3 Combined into one standard with four
FMS.4 measurable elements focused on risk assessment,
reporting, and action by the governing entity.
FMS.03.00 FMS.5 Renumbered standard with five measurable elements
focused on the safety program.
ME 4 focuses on safety incidents within the facility. X
ME 5 focuses on safety incidents related to
X
workplace violence.
FMS.04.00 FMS.6 Renumbered standard with nine measurable elements
focused on a secure environment.
ME 4 focuses on equipment inspection. X
ME 5 focuses on education related to a safety event. X
ME 6 focuses on safety exercises. X
ME 7 focuses on an annual analysis of workplace
X
violence.
ME 8 focuses on investigation of security incidents. X
ME 9 focuses on investigation of workplace
X
violence incidents.
FMS.05.00 FMS.7 Combined into one standard with seven measurable
FMS.7.1 elements focused on hazardous materials and waste.
FMS.7.2 ME 7 focuses on staff demonstration of procedures. X
FMS.06.00 FMS.8 Renumbered standard with three measurable ele-
ments focused on fire safety measures.
FMS.06.01 FMS.8.1 Combined into one standard with six measurable
FMS.8.2 elements focused on maintenance of fire safety equip-
ment/building features.
FMS.06.02 FMS.8.3 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
FMS.06.03 FMS.8.4 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
FMS.06.04 FMS.8.5 Renumbered standard with three measurable ele-
ments focused on patient and staff smoking habits.

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JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
FMS.07.00 FMS.9 Combined into one standard with three measurable
FMS.9.1 elements focused on medical equipment.
ME 2 combined concepts of previous FMS.9.1, MEs
2–4.
FMS.07.01 FMS.9.2 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
FMS.08.00 FMS.10 Combined into one standard with five measurable
FMS.10.1 elements focused on utility systems management.
FMS.08.01 FMS.10.2 Renumbered standard with three measurable
ele- ments focused on testing and evaluation of
utility systems.
FMS.08.02 FMS.10.3 Renumbered standard with four measurable elements
focused on monitoring water quality.
FMS.08.03 FMS.10.3.1 Renumbered standard with five measurable elements
similar to the 7th Edition.
FMS.08.04 PCI.10 Renumbered standard with three measurable ele-
ments focused on reducing the risk of infection X
through engineering controls.
FMS.09.00 FMS.11 Renumbered standard with four measurable elements
focused on the emergency management program.
FMS.09.01 PCI.12.1 New standard with six measurable elements focused
PCI.12.2 on emergency management for global communicable X
diseases.
FMS.10.00 FMS.12 Renumbered standard with three measurable ele-
PCI.11 ments similar to the 7th Edition.

Governance, Leadership, and Direction (GLD)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
GLD.01.00 GLD.1 Combined into one standard with five measurable
GLD.1.1 elements focused on structure and oversight
GLD.1.2 responsi- bilities of the governing entity.
GLD.02.00 GLD.2 Renumbered standard with five measurable elements
focused on the chief executive’s qualifications and
responsibilities.
GLD.03.00 GLD.3 Renumbered standard with three measurable ele-
ments focused on hospital leaders’ responsibility to
carry out the hospital’s mission.

xx
 SUMMARY OF CHANGES TO THE
MANUAL

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
GLD.03.01 GLD.3.1 Renumbered standard with four measurable elements
focused on hospital departments’ planning of ser-
vices, providing data, and communication to staff.
ME 4 focuses on implementing policies to provide
X
uniform care to patients.
GLD.03.02 GLD.3.2 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
GLD.04.00 GLD.4 Renumbered standard with seven measurable
ele- ments focused on implementation of
hospitalwide quality and patient safety program.
ME 5 focuses on definition of patient safety events
X
and reporting of sentinel events.
Moved QPS.7, ME 2 (7th Edition) to GLD.04.00,
ME 6 (8th Edition).
ME 7 focuses on supporting staff involved in
X
an adverse event or a sentinel event.
GLD.04.01 GLD.4.1 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
GLD.04.02 GLD.5 Renumbered standard with four measurable elements
focused on hospital leaders’ use of data when iden-
tifying hospitalwide priorities and compliance to
IPSGs.
ME 3 focuses on data collection and assessment of
X
diagnostic error factors.
ME 4 focuses on interventions to mitigate
X
diagnostic errors.
GLD.05.00 GLD.6 Combined into one standard with six measurable
GLD.6.1 ele- ments focused on oversight of contract
services and integration of contract management to
the hospital’s quality monitoring program.
GLD.05.01 GLD.6.2 Renumbered standard with four measurable elements
similar to the 7th Edition.
GLD.05.02 GLD.7 Renumbered standard with four measurable elements
focused on using data in resource decision-making.
GLD.05.03 GLD.7.1 Renumbered standard with three measurable ele-
ments focused on establishing the hospital’s supply
chain strategy.
ME 1 combines the concepts of GLD.7.1, MEs 1–
3 (7th Edition).
GLD.06.00 GLD.8 Combined into one standard with four
GLD.9 measurable elements focused on hospital
department oversight, direction, and structure.

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JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
GLD.06.01 GLD.11 Renumbered standard with four measurable elements
similar to the 7th Edition.
GLD.06.02 GLD.11.2 Renumbered standard with four measurable elements
similar to the 7th Edition.
GLD.07.00 GLD.12 Renumbered standard with six measurable elements
focused on the hospital’s ethical framework and con-
flict of interest disclosure.
GLD.07.01 GLD.13 Renumbered standard with six measurable elements
GLD.13.1 focused on culture of safety in the organization.
Moved GLD.13, ME 1 (7th Edition) to GLD.07.01,
ME 4 (8th Edition).
Moved GLD.13.1, ME 5 (7th Edition) to
GLD.07.01, ME 5 (8th Edition).
Moved GLD.13.1, ME 3 (7th Edition) to
GLD.07.01, ME 6 (8th Edition).
GLD.07.02 N/A New standard with five measurable elements
X
focused on workplace violence prevention
program.
GLD.08.00 GLD.14 Renumbered standard with five measurable elements
similar to the 7th Edition.
GLD.09.00 GLD.15 Renumbered standard with five measurable elements
focused on human subjects research policies, patient
information, consent forms, and indemnity insurance.

Health Care Technology (HCT)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
HCT.01.00 MOI.11 Renumbered standard from MOI with four measur-
able elements similar to the 7th Edition.
HCT.01.01 MOI.12 Renumbered standard from MOI with five measur-
able elements similar to the 7th Edition.
HCT.01.02 N/A New standard with four measurable elements focused
X
on telehealth services.
HCT.01.03 N/A New standard with three measurable elements
focused on clinical decision support tools and artifi- X
cial intelligence.
HCT.01.04 MOI.13 Renumbered standard from MOI with six
measurable elements similar to the 7th Edition.
HCT.01.05 N/A New standard with three measurable elements
X
focused on cybersecurity and cyber risk management.
HCT.02.00 COP.4 Renumbered standard from COP with six
measurable elements similar to the 7th Edition.

xxii
 SUMMARY OF CHANGES TO THE
MANUAL

Management of Information (MOI)

7th Edition
8th Edition (Previous)
Standard Standard New
Number(s) Number(s) Description of Changes Standard New ME
MOI.01.00 MOI.1 Renumbered standard with three measurable ele-
ments focused on managing information.
MOI.01.01 MOI.2 Renumbered standard with six measurable elements
similar to the 7th Edition.
MOI.01.02 MOI.2.1 Renumbered standard with five measurable elements
focused on safety and security of information.
ME 5 focuses on cyberattacks. X
MOI.01.03 MOI.3 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
MOI.01.04 MOI.6 Renumbered standard with four measurable elements
focused on information systems training.
ME 3 focuses on cybersecurity education. X
MOI.02.00 MOI.7 Renumbered standard with four measurable elements
focused on management of documents.
Split 7th Edition ME 1 into 8th Edition MEs 1
and 2.
MOI.02.01 MOI.7.1 Renumbered standard with four measurable elements
similar to the 7th Edition.
MOI.02.02 MOI.4 Renumbered standard with four measurable elements
focused on use of abbreviations.
MOI.02.03 MOI.5 Renumbered standard with three measurable ele-
ments focused on dissemination of data.
MOI.03.00 MOI.8 Combined into one standard with five measurable
MOI.8.1 elements focused on the integrity of the patient
MOI.9 health record.
MOI.03.01 MOI.10 Renumbered standard with five measurable elements
similar to the 7th Edition.

Prevention and Control of Infections (PCI)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
PCI.01.00 PCI.1 Renumbered standard with five measurable
elements focused on qualifications of infection
prevention and control leaders and oversight of the
infection preven- tion and control program.
PCI.01.01 PCI.2 Renumbered standard with five measurable elements
focused on integration of the infection prevention
and control program with all departments and
services, and with the quality and patient safety
program.

xxiii
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
PCI.01.02 PCI.3 Renumbered standard with three measurable ele-
ments focused on provision of adequate resources
for the infection prevention and control program.
PCI.02.00 PCI.5 Combined into one standard with five
PCI.5.1 measurable elements focused on risk
IPSG.5.1 assessments and evi- dence-based strategies for
infection prevention and control.
PCI.02.01 AOP.5.3.1 Renumbered standard moved to PCI chapter with
four measurable elements similar to the 7th Edition.
PCI.03.00 PCI.6 Renumbered standard with eight measurable ele-
ments similar to the 7th Edition.
PCI.03.01 PCI.6 New standard with five measurable elements
X
focused on a process to manage reuse of single-
use devices.
PCI.03.02 PCI.6 New standard with three measurable elements
focused on a process to manage expired and X
damaged devices and supplies.
PCI.04.00 PCI.7 Renumbered standard with four measurable elements
similar to the 7th Edition.
PCI.04.01 PCI.7.1 Renumbered standard with four measurable elements
similar to the 7th Edition.
PCI.05.00 PCI.8 Renumbered standard with seven measurable
ele- ments focused on proper disposal and
handling of infectious waste, sharps, and
needles.
ME 7 focuses on a policy to direct chain of
custody for all bodies and body parts handled by X
pathology, mortuary, and other postmortem
areas.
PCI.05.01 PCI.8.1 Renumbered standard with seven measurable ele-
ments focused on protection from and response to
blood and body fluid exposures.
ME 2 focuses on implementation of practices to
X
reduce risk of exposures to blood and body fluids.
PCI.06.00 PCI.9 Renumbered standard with five measurable elements
similar to the 7th Edition.
PCI.07.00 PCI.12 Renumbered standard with five measurable elements
focused on isolation precautions for communica-
ble diseases and protection of immunosuppressed
patients.
ME 2 focuses on staff education on management
of infectious patients when negative air pressure X
rooms are not available.

xxi
v
 SUMMARY OF CHANGES TO THE
MANUAL

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
PCI.07.01 PCI.13 Renumbered standard with six measurable
elements focused on personal protective
equipment and hand hygiene resources.
ME 2 focuses on ensuring that personal
protective equipment and hand hygiene resources X
are readily available.
PCI.07.02 N/A New standard with five measurable elements
focused on preparedness and response for
X
epidemiologically significant or high-impact
pathogens, including novel pathogens.
PCI.08.00 PCI.14 Renumbered standard with five measurable elements
similar to the 7th Edition.
PCI.08.01 PCI.15 Renumbered standard with five measurable elements
focused on infection prevention and control educa-
tion for staff and infection prevention and control
program communication with leaders and governing
board.
ME 5 focuses on communicating data and
informa- tion from infection prevention and X
control program to governing board.

Quality and Patient Safety (QPS)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
QPS.01.00 QPS.1 Renumbered standard with six measurable elements
focused on implementation of quality and patient
safety program and quality and patient safety pro-
gram leaders/staff qualifications.
ME 6 focuses on defining qualifications of quality
X
and patient safety program leaders and staff.
QPS.02.00 QPS.2 Renumbered standard with four measurable elements
similar to the 7th Edition.
QPS.03.00 QPS.4 Renumbered standard with five measurable elements
similar to the 7th Edition.
QPS.03.01 QPS.6 Renumbered standard with three measurable ele-
ments focused on data validation.
QPS.03.02 QPS.4.1 Renumbered standard with five measurable elements
similar to the 7th Edition.
QPS.03.03 QPS.5 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.

xxv
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
QPS.03.04 QPS.8 Renumbered standard with six measurable elements
focused on mandatory data collection, intensive
analysis when adverse events or trends occur, and
reporting of data analyses.
ME 6 focuses on implementing measures intended
X
to increase patient safety event reporting.
QPS.04.00 QPS.9 Renumbered standard with four measurable elements
similar to the 7th Edition.
QPS.04.01 QPS.10 Renumbered standard with six measurable elements
focused on requirements for risk management
programs.
ME 6 focuses on defining qualifications of risk man-
X
agement personnel.

Staff Qualifications and Education (SQE)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
SQE.01.00 SQE.1 Renumbered standard with three measurable elements
similar to the 7th Edition.
SQE.01.01 SQE.1.1 Renumbered standard with four measurable elements
focused on staff member responsibilities in the job
description.
ME 2 focuses on requiring the job description to
X
include defined staff member responsibilities.
SQE.01.02 SQE.2 Renumbered standard with four measurable elements
similar to the 7th Edition.
SQE.01.03 SQE.3 Combined into one standard with six measur-
SQE.4 able elements focused on staff qualifications and
performance.
ME 2 focuses on performance-based staff evaluations. X
ME 5 focuses on a qualified individual
X
conducting staff evaluations.
SQE.01.04 SQE.5 Renumbered standard with three measurable elements
similar to the 7th Edition.
SQE.01.05 SQE.6 Combined into one standard with seven measurable
SQE.6.1 elements focused on hospital staffing process.
ME 4 focuses on staffing process compliance with
X
laws and regulations.

xxv
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 SUMMARY OF CHANGES TO THE
MANUAL

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
SQE.01.06 SQE.7 Renumbered standard with five measurable elements
focused on staff orientation.
ME 5 focuses on documentation of completed
X
orientation.
SQE.01.07 SQE.8 Renumbered standard with seven measurable ele-
ments focused on education and training.
ME 7 focuses on documentation of completed
X
educa- tion and training.
SQE.01.08 SQE.8.1 Combined into one standard with seven
SQE.8.1.1 measurable elements focused on staff competence
in resuscitative techniques.
SQE.02.00 SQE.8.2 Renumbered standard with five measurable elements
focused on staff mental health.
ME 3 focuses on the evaluation and resources for
X
elements of staff mental health.
ME 5 focuses on actions taken for staff mental
X
health prevention.
SQE.02.01 SQE.8.3 Renumbered standard with five measurable elements
focused on a staff vaccination and immunization
program.
ME 3 focuses on a process for staff vaccinations and
X
immunizations.
SQE.02.02 N/A New standard with three measurable elements
X
focused on workplace violence prevention training.
SQE.03.00 SQE.13 Renumbered standard with six measurable elements
similar to the 7th Edition.
SQE.03.01 SQE.14 Renumbered standard with five measurable elements
focused on nursing staff credentials.
ME 1 focuses on nursing staff experience, training,
X
and education applicability to their role.
ME 2 focuses on nursing staff evaluation criteria. X
SQE.03.02 SQE.14.1 Renumbered standard with three measurable elements
similar to the 7th Edition.
SQE.04.00 SQE.15 Renumbered standard with five measurable elements
similar to the 7th Edition.
SQE.04.01 SQE.16 Renumbered standard with three measurable elements
similar to the 7th Edition.
SQE.04.02 SQE.16.1 Renumbered standard with three measurable elements
similar to the 7th Edition.
SQE.05.00 SQE.9 Renumbered standard with four measurable elements
similar to the 7th Edition.

xxvii
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
SQE.05.01 SQE.9.1 Renumbered standard with three measurable elements
similar to the 7th Edition.
SQE.05.02 SQE.9.2 Renumbered standard with three measurable elements
similar to the 7th Edition.
SQE.06.00 SQE.10 Renumbered standard with five measurable elements
focused on the process to grant medical staff
member- ship and clinical privileges.
ME 2 focuses on criteria that determine scope of
X
medical staff privileges.
Moved PCC.4.3, ME 4 (7th Edition) to SQE.06.00,
X
ME 5 (8th Edition).
SQE.06.01 N/A New standard with six measurable elements focused
X
on medical staff temporary clinical privileges.
SQE.06.02 SQE.12 Renumbered standard with six measurable elements
focused on medical staff membership and clinical
privileges.
ME 4 focuses on notification of staff regarding the
X
decision to grant privileges.
ME 5 focuses on the process to disseminate all
X
grant- ing-related decisions to applicable parties.
SQE.07.00 SQE.11 Renumbered standard with five measurable elements
focused on process for evaluating the care provided
by the medical staff.
ME 4 focuses on hospitalwide and department/ser-
vice data sources criteria used in medical staff X
ongoing evaluations.
SQE.07.01 N/A New standard with five measurable elements
focused on monitoring and evaluating medical X
staff profes- sional performance.

Global Health Impact (GHI)

All-new chapter and requirements. Did not exist in 7th Edition.

Human Subjects Research Programs (HRP)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
HRP.01.00 HRP.1 Renumbered standard with four measurable elements
HRP.1.1 similar to the 7th Edition.
Moved HRP.1.1, ME 2 (7th Edition) to
HRP.01.00, ME 4 (8th Edition).

xxv
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 SUMMARY OF CHANGES TO THE
MANUAL

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
HRP.01.01 HRP.2 Renumbered standard with five measurable elements
similar to the 7th Edition.
HRP.01.02 HRP.3 Renumbered standard with three measurable elements
HRP.3.1 focused on a policy for sponsors of research.
Moved HRP.3, MEs 1–5 (7th Edition) to elements
under HRP.01.02, ME 1 (8th Edition).
ME 2 focuses on leaders verifying sponsor
X
qualifications.
ME 3 focuses on documentation confirming sponsor
X
responsibility and accountability.
HRP.01.03 HRP.3.1 Renumbered standard with four measurable elements
similar to the 7th Edition.
HRP.01.04 HRP.4 Renumbered standard with six measurable elements
similar to the 7th Edition.
HRP.02.00 HRP.5 Renumbered standard with four measurable
elements focused on managing conflict of interest
with research conducted in hospitals.
ME 1 focuses on a conflict of interest policy for
X
research in hospitals.
HRP.02.01 HRP.6 Renumbered standard with three measurable elements
similar to the 7th Edition.
HRP.02.02 HRP.7 Renumbered standard with four measurable elements
HRP.7.1 similar to the 7th Edition.
Moved Standard HRP.7 (7th Edition) to HRP.02.02,
ME 1 (8th Edition).

Medical Professional Education (MPE)

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
MPE.01.00 MPE.1 Renumbered standard with five measurable elements
similar to the 7th Edition.
MPE.01.01 MPE.2 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
MPE.01.02 MPE.3 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.
MPE.02.00 MPE.4 Renumbered standard with five measurable elements
focused on the supervision of medical students and
trainees.
ME 2 focuses on the participant roles and responsi-
X
bilities of the professional education programs.

xxix
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION

7th Edition
8th Edition (Previous)
Standard Standard New New
Number(s) Number(s) Description of Changes Standard ME
MPE.02.01 MPE.5 Renumbered standard with four measurable elements
similar to the 7th Edition.
MPE.02.02 MPE.6 Renumbered standard with five measurable elements
similar to the 7th Edition.
MPE.02.03 MPE.7 Renumbered standard with three measurable ele-
ments similar to the 7th Edition.

xxx
 Introduction

This introduction presents Joint Commission International (JCI) and explains how Joint Commission
International Accreditation Standards for Hospitals, 8th Edition, is organized. Like each of the seven previous
editions, we have sought to reflect the most current thinking in patient safety practices and concepts to
help accredited and nonaccredited organizations uncover their most pressing safety risks and advance their
goals for continuous quality improvement. We hope to support your work of making health care as safe as
possible.
Read this chapter first to understand the structure and the content of this manual. This introduction provides
information on the following topics:
• The value of JCI accreditation
• The standards development process
• How the manual is organized
• Applying the standards in your organization
• How to use the standards manual
• General eligibility requirements
After you have a better understanding of how to use this manual, read the “General Eligibility
Requirements” section of this introduction to check whether your organization is eligible for JCI
accreditation. Then become familiar with the JCI standards chapters and how the standards make health
care safer.
If you have questions about the standards or the accreditation process, please contact JCI at JCIAccreditation@
jcrinc.com.

The Value of JCI Accreditation

JCI’s Gold Seal of Approval® is a widely recognized benchmark representing the most comprehensive
evaluation process in the health care industry. Joint Commission accreditation benefits your organization in
the following ways:
• Gives you a competitive advantage: Achieving accreditation and specialty certification is a
visible demonstration to patients and the community that your hospital is committed to
providing the highest-quality services. It also sets you apart from other hospitals offering the
same types of care, treatment, and services.
• Assists with recognition from insurers, associations, and other third parties: Many payers, regulatory
agencies, government agencies, and managed care contractors require JCI accreditation for
reimbursement, for certification or licensure, and as a key element of their participation agreements
and reimbursement practices.
• Helps organize and strengthen performance improvement efforts: Accreditation encompasses state-of-the-
art performance improvement concepts that help you continuously improve quality and standardize
your processes of care, treatment, and services.
• Helps health care organizations become high reliability organizations: JCI offers numerous resources
and information to help hospitals move toward high reliability—that is, to consistently perform
at high levels of quality and safety across all services and to maintain these levels over long

1
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 8TH EDITION
periods.

2
 INTRODUCTIO
N

These resources help leaders commit to high reliability by making it a priority, establishing a safety
culture throughout the organization that emphasizes trust and the reporting of unsafe conditions and
opportunities for improvement.
• Enhances staff education: The accreditation process is designed to be educational. JCI surveyors share
best practice approaches and strategies that may help your hospital better meet the intent of the
standards and, more important, improve performance of day-to-day operations.
• Provides access to experts in quality and safety: JCI is committed to helping your hospital move
toward highly reliable care, treatment, and services. Through JCI your hospital has access to a
range of professionals eager to see you succeed. It starts with the assignment of an account manager
specializing in hospitals to help in day-to-day accreditation activities. You also have ready access to
the clinical and engineering experts in our Standards Interpretation Group (SIG) as well as professional
surveyors who visit your organization for surveys.

Standards Development Process

The JCI standards development process represents a collaboration between JCI, accredited organizations, and
global subject matter experts in patient quality and safety. This 8th edition considers developments in the
science of quality improvement and patient safety as well as the experiences of the organizations that used the
7th edition hospital and academic medical center standards to improve the safety and quality of care in their
organizations.
The JCI standards development team took the following actions in revising the standards for this edition:
• Conducted focus groups with leaders from JCI–accredited organizations and other health care experts
representing a broad range of perspectives from around the world.
• Reviewed the literature for current evidence-based practice and processes, and authoritative sources
for industry guidelines to support new and revised standards.
• Gathered input from experts and others with specific and relevant content knowledge, including
JCI surveyors and consultants.
• Received guidance on the development and revision of the standards from the Technical
Advisory Panel, an international panel composed of experts with extensive experience in various
health care fields.
• Sent an online field review of the revised standards to all accredited hospitals and promoted public
participation in the field review through social media and the JCI website.
• Overall, the standards revisions were influenced and guided by the following sources:
o Suggestions identified in the focus groups, advisory panels and subject matter experts, and
field review
o Requests to clarify requirements and expectations for specific standards
o Evolving health care practices, evidence-based guidelines, and the changing health
care environment

Keep Current with Standard Changes

JCI gathers information and experience related to the standards on an ongoing basis. If a standard no
longer reflects evidence-based health care practice, commonly available technology, and quality management
practices, JCI will revise or delete the requirements. New and revised standards are published at least six
months in advance of the effective date to provide time for organizations to come into full compliance
with the revised standards by the time they are effective.
JCI Insight provides critical information about changes to standards and policies that are made throughout
the year. Reading JCI Insight allows you to learn about initiatives underway to support your efforts to achieve
and sustain performance excellence. Note the changes because your organization is responsible for
complying with all applicable JCI standards (new and revised), including any changes published in
JCI Insight.

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Current and recent editions of JCI Insight are available on your organization’s extranet (JCI Direct
Connect) site, made available to organizations that are accredited or have applied for accreditation. Staff
who don’t have access to their organization’s secure extranet site can “Request Guest Access” on JCI’s
website at https://www. jointcommissioninternational.org/resources/jcinsight-newsletter.

Effective Date of Standards

The Joint Commission International Accreditation Standards for Hospitals, 8th Edition, is effective 1 January
2025:
1. For currently accredited hospitals, this is the date by which you now must be in full compliance
with all new and revised standards in the 8th edition.
2. For hospitals seeking accreditation for the first time, this is the date after which all surveys and
accreditation decisions will be based on the standards of the 8th edition. If you apply for survey
and are surveyed before 1 January 2025, the survey will assess compliance with the standards of
the 7th edition.

How This Manual Is Organized

This manual includes all the hospital and academic medical center Accreditation Participation Requirements
(APRs), standards, intents, and measurable elements (MEs). The standards are organized around the important
functions common to all health care organizations—an approach widely used around the world, which has
been validated by scientific study, testing, and application.
This manual contains five major sections:
1. Accreditation Participation Requirements (Section I) that outline specific requirements for
participating in accreditation and maintaining an accreditation award
2. Standards related to providing patient care (Section II)
3. Standards related to providing a safe, effective, and well-managed organization (Section III)
4. Standards related to environmental, social, and governance that impacts health care organizations
(Section IV)
5. For academic medical centers only, standards related to medical professional education and human
subjects research programs (Section V)
The standards apply to the entire organization as well as to each department, unit, or service within the
organization.
In addition to the accreditation requirements, this manual includes the following appendices:
• Interim Measures: Interim measures are actions taken to ensure the safety of the building’s
occupants during times when features and systems for fire safety are defective, compromised, or
inoperable due to construction, maintenance, a breakdown, or repair. Interim measures may need to
be implemented to ensure the safety of occupants until improvements or repairs can be
completed.
• Patient Safety Systems: Informs and educates leaders about the importance and structure of
an integrated patient safety system. This chapter is designed to clarify the relationship between
JCI accreditation and patient safety. It does not contain new standards or requirements. Rather,
the chapter describes how existing requirements can be applied to continually improve patient
safety. It also provides approaches and methods that may be adapted to remove risk of patient
harm.
• Sentinel Event Policy: Contains information on JCI’s Sentinel Event Policy, including the definition
of a sentinel event, the goals of the policy, the adverse events that constitute sentinel events,
sentinel event–related standards, and the various activities that surround the policy.
The manual also includes “Summary of Changes to the Manual,” “Introduction,” a chapter describing the
key accreditation policies, and a glossary.

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The companion Joint Commission International Survey Process Guide for Hospitals Including Academic Medical
Centers, 8th Edition, helps hospitals and academic medical centers learn about and prepare for the JCI
accreditation survey. During the survey, surveyors gather standards compliance information throughout
the entire organization. The accreditation decision is based on the organization’s overall level of compliance
with the standards in this manual.

Elements of a Standards Chapter

Each standards chapter in Sections II, III, IV, and V contains the following elements:
• Overview: The overview is located at the beginning of each chapter. The overview explains the
chapter’s purpose and the principles on which the standards were built.
• Standards list: This part shows how the chapter is laid out and provides a frame of reference for
the numbering of standards.
• Standards: Standards (also known as requirements) are statements that define the performance
expectations and/or structures or functions that must be in place for an organization to be
accredited by JCI and to provide safe, high-quality care, treatment, and services. Standards are
evaluated for compliance during the on-site survey.
• Intent: An intent helps explain the full meaning of a standard by providing additional
background, justification, or other information. The intent describes the purpose or reason for
the standard and how it fits into the overall program, setting parameters for what is required by
the standard. The intent is considered advisory, and it is not scored.
• Measurable elements (MEs): MEs are statements that detail the specific performance expectations,
structures, functions, or processes that must be in place for an organization to meet the standard
and provide high-quality care, treatment, and services. MEs are reviewed during the on-site survey
and assigned a score that determines an organization’s overall compliance with a standard.
Organizations can use MEs to bring clarity to standards, help the organization fully understand
the requirements, guide the organization in accreditation preparation, and educate executive leaders,
department/service leaders, health care practitioners, and staff about the standards.
• Examples: Examples are included in many standards’ intents and MEs to better illustrate
expectations for compliance. Examples are considered advisory and are not required or scored.
• Notes: Occasionally, notes are used to provide organizations and surveyors with additional or
clarifying information. A note may provide applicability information, define a term, or explain a
concept. (All key terms are defined in the “Glossary” in the back of this manual.)

Required Written Documentation

Joint Commission International’s focus is on performance and implementation rather than documentation.

The standards, consequently, require documentation only when it is essential. The documentation icon—Ⓓ
— is used to identify data collection and documentation requirements that are in addition to information
found in the medical record. For example, the documentation icon is applied to an ME that requires a
written procedure, but the icon is not applied to an ME that lists the required components of the medical
record.
Other examples in which the documentation icon is applied are MEs that require a policy, a written plan,
bylaws, a license, evidence of testing, data, performance improvement reports, medication labels, safety data
sheets, and meeting minutes.
Documentation can be on paper or in an electronic format. Although documentation is important, the
primary emphasis of the survey will be on how your hospital carries out the functions described in the
standards. The surveyors may use a combination of data sources, including interviews with leaders of
the hospital, staff, patients, and patients’ family members; visits to patient care settings; and review of
documentation to arrive at an assessment of your hospital’s compliance with a standard.
The documentation icon is meant to be a guide. The names and format of specific documents may vary from
organization to organization.
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JCI Standards in the Public Domain

To help individual health care organizations and public agencies seeking to improve the quality of patient
care, JCI hospital standards (but not the intent statements and MEs) are in the international public domain
for viewing. A listing of JCI hospital standards can be downloaded at no cost from the JCI website at
https:// www.jointcommissioninternational.org. Organizations with questions about translating or using the
JCI standards must request written permission by contacting [email protected].

Applying the Standards in Your Organization

Although each standard in Sections II, III, and IV apply to all applicant hospitals, there are three special
circumstances when considering how to apply standards in an individual hospital:

Adhering to the Stricter Standard

A hospital must establish policies and procedures that conform to national, regional, and local laws or
regulations as well as JCI standards. When a concept is addressed by the JCI standards and by the laws or
regulations of a national or local authority, JCI requires that an organization follow whichever body has
set the higher or stricter requirement. For example, JCI requires that organizations use two patient
identifiers in a variety of processes. If the hospital’s national standard requires the use of three identifiers,
the hospital must use three identifiers to meet the national standard, which is stricter than JCI’s standard.
However, if that same national standard allows the use of bed number as an identifier—a practice JCI
explicitly prohibits—the organization is prohibited from doing so. In this case, the organization would need
to use three identifiers (the
stricter national requirement) and would be prohibited from using bed number as an identifier (the stricter JCI
requirement).

Global Health Impact (GHI) Standards

The Joint Commission International Accreditation Standards for Hospitals, 8th Edition, introduces a new
chapter on Global Health Impact (GHI) that focuses on environmental sustainability in health care
organizations.
Standards in the GHI chapter are developed in collaboration with the International Hospital Federation’s
Geneva Sustainability Centre.
Understanding that hospitals are in different stages of their environmental sustainability journey, this chapter
will serve as a resource to standardize practices in the environmental sustainability initiatives of JCI-
accredited hospitals. Standards in the GHI chapter will be scored but will not factor into the organization’s
JCI accreditation decision for organizations surveyed before 1 January 2026.

Academic Medical Center Standards

Although community medical centers, often called hospitals or acute care centers, provide a wide range of
basic and specialized services for patients in their local communities, academic medical centers are also
primary sites for medical education and health care research. JCI developed the academic medical center
standards
to recognize the unique resource such organizations represent for health professional education and human
subjects research in their community and country.
JCI standards in Section V, the “Medical Professional Education” (MPE) and “Human Subjects Research
Programs” (HRP) chapters, present a framework for including medical education and research into the
quality and patient safety activities of academic medical centers.
Many health care organizations may consider themselves to be an academic medical center, but only
organizations that meet JCI’s definition are required to comply with the MPE and HRP standards presented in
Section V of this manual.

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JCI will consider an applicant hospital an eligible academic medical center if it meets the following three
criteria:
1. It is integrated (by organization or administration) with a medical school.
2. It is the principal site for the education of both (a) medical students (that is, undergraduates) and
(b) postgraduate medical specialty trainees (for example, residents or interns) from such medical
school.
3. At the time of application, it conducts medical research with approval and oversight by an
Institutional Review Board (IRB) or research ethics committee.
All hospitals meeting the academic medical center eligibility criteria must comply with the requirements in
Section V (as well as the requirements detailed in Sections II and III) to achieve JCI accreditation.
Organizations with questions about their eligibility for academic medical center accreditation should contact
JCI Accreditation’s Central Office at [email protected].

Using the Standards Manual

Joint Commission International Accreditation Standards for Hospitals, 8th Edition, when paired with its
companion book Joint Commission International Survey Process Guide for Hospitals Including Academic Medical
Centers, 8th Edition, along with information on the organization’s JCI Direct Connect extranet site, together
contain all the information a hospital needs to achieve and maintain continuous compliance with JCI
hospital accreditation standards.
Communicating critical information to staff and maintaining continuous compliance with JCI standards
are keys to ensuring that safe, high-quality care is provided to patients—yet these goals present a real
challenge for many organizations. Following are some helpful suggestions for successfully achieving
continuous compliance with accreditation standards outlined in this accreditation manual:
• Become familiar with the standards. Review the important functions of a health care organization
identified in the titles of the standards chapters. Become aware of those standards that all
organizations must meet to be accredited by JCI and review the compliance expectations of the
standards as well as those of the additional requirements found in the associated intents and
MEs. Become familiar with the terminology used in the manual. Identify those standards that
require documentation (also outlined in the Joint Commission International Survey Process Guide for
Hospitals Including Academic Medical Centers, 8th Edition) and make sure you have the needed
documentation to maintain compliance.
• Visit your organization’s extranet site. Become aware of the accreditation policies and procedures and
the accreditation process. Discover how to find the information you need about an upcoming
survey or a revised requirement.
• Use the standards to improve care, treatment, and services. Hospitals should not view accreditation
standards as rules that must be followed just for the JCI survey. Instead, incorporate tasks and
processes that help integrate these concepts into your daily operations because they directly affect
the safety of patients and the quality of care, treatment, and services you provide. As you self-
assess your compliance with JCI surveys, identify follow-up actions needed to bring your
organization into compliance and meet the needs of your patients for safe, high-quality care.
JCI’s accreditation policies and procedures, as well as information about JCI’s hospital accreditation process
— including the presurvey, on-site survey, and postsurvey activities—can be found in their entirety on an
accredited organization’s secure JCI Direct Connect extranet site. They are also summarized in this manual.

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General Eligibility Requirements

Any hospital may apply for JCI accreditation if it meets all the following criteria:
• The hospital is located outside of the United States and its territories.
• If required by law, the organization has a facility license or registration to conduct its scope of services.
• The hospital is currently operating as a health care provider in the country, is licensed to provide care
and treatment as a hospital (if required), and, at minimum, does the following:
o Provides a complete range of acute care clinical services—diagnostic, curative, and rehabilitative.
o Provides services that are available 365 days per year; ensures that all direct patient care
services are operational 24 hours per day, 7 days per week; and provides ancillary and support
services as needed for emergent, urgent, and/or emergency needs of patients 24 hours per
day, 7 days per week (such as diagnostic testing, laboratory, and operating theatre, as
appropriate to the type of acute care hospital).
o In the case of a specialty hospital, provides a defined set of services, such as pediatric, eye,
dental, and psychiatry, among others.
• The hospital meets parameters for the minimum number of inpatients/volume of services
required for organizations seeking initial or continued Joint Commission accreditation; that is, 10
inpatients served, with 1 active at the time of survey.
• The hospital provides services that can be evaluated by JCI accreditation standards for hospitals.
• The hospital assumes, or is willing to assume, responsibility for improving the quality of its care
and services.
• The hospital is open and in full operation, admitting and discharging a volume of patients that
will permit the complete evaluation of the implementation and sustained compliance with all
current JCI accreditation standards for hospitals.
• The hospital meets the conditions described in the “Accreditation Participation Requirements” (APR)
chapter.
In addition, academic medical center applicants must meet the additional following criteria:
• The applicant hospital is integrated (by organization or administration) with a medical school.
• The applicant hospital is the principal site for the education of both (1) medical students
(undergraduates) and (2) postgraduate medical specialty trainees (for example, residents or
interns) from such medical school.
• At the time of application, the applicant hospital is conducting medical research with approval
and oversight by an Institutional Review Board (IRB) or research ethics committee.
Contact JCI at [email protected] prior to submitting an electronic application (that is, E-
App) to discuss the criteria and validate whether the hospital meets the above criteria as well as the
definition for “in full operation” (in the sidebar “Understanding Terms” on page 8) at least six months
or more prior to submitting its E-App and at its initial survey. JCI may request documentation of the
hospital’s utilization statistics prior to accepting the E-App or conducting the on-site survey. In
addition, JCI will not begin a
survey, may discontinue a survey, or may cancel a scheduled survey when it determines the hospital is not “in
full operation.”
Note: If in its reasonable discretion JCI determines that the applicant does not meet the eligibility criteria
for the hospital/academic medical center accreditation program JCI will not accept or process the E-App
and will notify the hospital of its decision.

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Understanding Terms
Full Operation
Criteria indicating the organization’s readiness for comprehensive evaluation against all relevant JCI
standards, based on identification of the following in the organization’s electronic application for survey
(E-App):
1. A list of all clinical services currently provided for inpatients and outpatients. (Those
clinical services that are planned, and thus not identified in the E-App, and begin
operations at a later time will require a separate extension survey to evaluate those
services.)
2. Utilization statistics for clinical services showing consistent inpatient and outpatient activity
levels and types of services provided for at least four months or more prior to submission of
the organization’s electronic application.
3. All inpatient and outpatient clinical services, units, and departments. These locations must
be available for a comprehensive evaluation against all relevant JCI standards for hospitals
currently in effect, consistent with JCI’s normal survey process for the size and type of
organization, such as the following:
• Patient tracer activities, including individual patient and system tracers
• Open and closed medical record review
• Direct observation of patient care processes
• Interviews with patients
• Interviews with medical students/trainees

Principal site
The location at which the hospital provides the majority of medical specialty programs for
postgraduate medical trainees (for example, residents or interns) and not just one specialty, as in a
single-specialty organization (for example, an ophthalmologic hospital, a dental hospital, or an
orthopedic hospital).

Medical research
Basic, clinical, and health services research that includes many types of research studies, such as
clinical trials, therapeutic interventions, development of new medical technologies, and outcomes
research, among others. (Hospitals that primarily conduct non–human subjects research and/or
research exempt from review by an Institutional Review Board
or research ethics committee, such as medical record review studies, case studies, and research involving
data/specimens without individually identifiable information, do not meet criterion 3 of the academic
medical center eligibility criteria.)