#

STANDARD AND SCORING REQUIREMENTS

d)

responding to the psychological, emotional,

spiritual, and cultural concerns of the patient and
family
HRC.49 As appropriate to the care and services provided,
assessments and reassessments of the dying patient and
their family are designed to meet individualized needs.
Measurable Elements:
1. Patients and families are assessed and reassessed for the
following elements:
a) symptoms such as nausea and respiratory distress;
b) current symptom management and the patients
response;
c) patient and family spiritual orientation and, as
appropriate, any involvement in a religious group;
d) the need for support or respite services for the
patient, family, or other caregivers;
e) the need for an alternative setting or level of care
2. Assessment findings guide the care and services
provided.

Pain Management
HRC.50 Patients are supported in managing pain effectively.
Measurable Elements:
1. The hospital has processes to assess and manage pain
appropriately, including:
a) identifying patients with pain during initial
assessment and reassessment;
b) providing management of pain according to
guidelines or protocols;
c) communicating with and educating patients and
families about pain and symptom management in
the context of their personal, cultural, and religious
beliefs;
d) educating health care providers about pain
assessment and management.

Infection Control
HRC.51 One or more individuals oversee all infection prevention
and control activities. This individual(s) is qualified in
infection control practices through education, training,
experience, or certification.
Measurable Elements:
1. One or more individuals oversee the infection control
program.
2. The individual(s) is qualified for the hospitals size, level
of risks, and program scope and complexity.

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NM

N/A

HRC.52
M

STANDARD AND SCORING

REQUIREMENTS
3. The
individual(s)
fulfill
program
oversight
responsibilities as assigned or described in a job
description.
The organization uses risk, rate, and trend information to
design or modify processes to reduce infections to the
lowest possible levels.
Measurable Elements:
1. Processes are redesigned based on risk, rate, and trend
data and information.

M
HRC.53
M

M
HRC.54

HRC.55
M

2. Processes are redesigned to reduce infection risk to the

lowest levels possible.
The infection control program is based on current
scientific knowledge, accepted practice guidelines, and
applicable law and regulation.
Measurable Elements:
1. The infection control program is based on current
scientific knowledge.
2. The infection control program is based on accepted
practice guidelines.
3. The infection control program is based on applicable
law and regulation.
The hospitals leaders provide adequate resources to
support the infection control program.
Measurable Elements:
1. The infection control program is adequately staffed as
approved by the leadership.
2. The hospitals leaders allocate adequate resources for
the infection control program.
3. Information management systems support the
infection control program.
The hospital designs and implements a comprehensive
program to reduce the risks of health care-associated
infections in patients and health care workers.
Measurable Elements:
1. There is a comprehensive program and plan to reduce
the risk of health care-associated infections in patients.
2. There is a comprehensive program and plan to reduce
the risk of health care-associated infections in health
care workers.
3. The program includes systematic and proactive
surveillance activities to determine usual rates of
infection.
4. The program includes systems to investigate outbreaks
of infectious diseases.

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STANDARD AND SCORING

REQUIREMENTS

5. Risk-reduction goals and measurable objectives are

established, regularly reviewed, and revised at least
annually.
M
6. Incidences of diseases are reported to the appropriate
authorities within the established regulatory
timeframes.
M
7. The staff are free of diseases as required by law or
regulation
HRC.56 All areas of the organization are included in the infection
control program as appropriate.
Measurable Elements:
1. All patient care areas of the hospital are included in
the infection control program.
2. All staff areas of the hospital are included in the
infection control program.
3. All visitor areas of the hospital are included in the
infection control program.
4. All additional areas of the hospital are included as
applicable
(e.g.,
radiology,
laboratory,
construction/renovation sites, etc.)
The hospital establishes the focus of the health careHRC.57 associated infection prevention and reduction program
consistent with laws, regulations, and acceptable practices.
M
Measurable Elements:
M
1. Respiratory tract infections are included.
M
2. Urinary tract infections are included.
M
3. Intravascular invasive devices are included.
M
4. Surgical wounds are included.
M
5. Epidemiologically significant diseases and organisms
are included.
M
6. Emerging or re-emerging infections are included.
The hospital reduces the risk of infections by ensuring
HRC.58 adequate equipment cleaning and sterilization and the
proper management of laundry and linen.
M
Measurable Elements:
1. Equipment cleaning and sterilization methods in a
central sterilization service are appropriate for the
type of equipment.
2. Equipment cleaning, disinfection, and sterilization
methods conducted outside of a central sterilization
service are appropriate for the type of equipment.
3. Laundry and linen management are appropriate to
minimize risk to staff and patients.

- 4046
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NM

N/A