Patient-Centered Care-How it connect with ‘Care of Patients (COP)’ JCIA hospital standards? KISS(!)..

Modern physicians are now practicing patient-centered care to improve their patients’ clinical outcomes and satisfaction rates by improving the quality of the doctor-patient relationship, while at the same time decreasing the utilization of diagnostic testing, prescriptions, hospitalizations, and referrals.  Patient-centered practitioners focus on improving different aspects of the patient-physician interaction by employing measurable skills and behaviors. This type of care can be employed by physicians in any specialty, and it is effective across disease types. Patient-centered care replaces our current physician centered system with one that revolves around the patient. Effective care is generally defined by or in consultation with patients rather than by physician dependent tools or standards. As an example, orthopedic surgeons employ the Harris Hip Score to judge the success of total hip replacements. It was designed solely by physicians and does not even ask patients to rate their satisfaction with the procedure; it answers questions important to doctors and thought to be important to patients; however, it is unknown whether almost any physician derived tools, such as the Harris Hip Score, accurately reflect the patient experience with a hip replacement or other aspects of their medical care. The Institute of Medicine (IOM) defines patient-centered care as: ‘Health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care’. The term “patient-centered care” was originally coined by the Picker Commonwealth Program for Patient-Centered Care, which later became ‘The Picker Institute’ that measure the following eight dimensions: (1) Respect for patient-centered values, preferences, and expressed needs, including an awareness of quality-of-life issues, involvement in decision-making, dignity, and attention to patient needs and autonomy, (2) Coordination and integration of care across clinical, ancillary, and support services and in the context of receiving “frontline” care, (3) Information, communication, and education on clinical status, progress, prognosis, and processes of care in order to facilitate autonomy, self-care, and health promotion, (4) Physical comfort, including pain management, help with activities of daily living, and clean and comfortable surroundings, (5) Emotional support and alleviation of fear and anxiety about such issues as clinical status, prognosis, and the impact of illness on patients, their families and their finances, (6) Involvement of family and friends in decision-making and awareness and accommodation of their needs as caregivers, (7) Transition and continuity as regards information that will help patients care for themselves away from a clinical setting, and coordination, planning, and support to ease transitions, and (8) Access to care, with attention to time spent waiting for admission or time between admission and placement in a room in the inpatient setting, and waiting time for an appointment or visit in the outpatient setting. Therefore patient-centered care has now made it to center stage in discussions of quality. Patient-centered care is a quality of personal, professional, and organizational relationships. Thus, efforts to promote patient-centered care should consider patient-centeredness of patients (and their families), clinicians, and health systems. Helping patients is to be more active in consultations changes centuries of physician-dominated dialogues to those that engage patients as active participants. Training physicians to be more mindful, informative, and emphatic transforms their role from one characterized by authority to one that has the goals of partnership, solidarity, empathy, and collaboration. Systems changes that unburden primary care physicians from the drudgery of productivity-driven assembly-line medicine can diminish the cognitive overload and exhaustion that makes medical care anything but caring or patient-centered. Confusion about what patient-centered care really means, however, can produce efforts that are superficial and unconvincing. In the name of patient centeredness, hospitals have been adopting models used by boutique hotels with greeters, greenery, and gadgetry. Although such amenities might enhance the patient’s experience, they do not necessarily achieve the goals of patient-centered care. Calls for patient-centered care have often emphasized the implementation of infrastructural changes. These changes, such as electronic health records and advanced access scheduling, may be necessary to move medical care into the 21st century, but they should not be conflated with achieving patient-centered care. Simply implementing an electronic health record in itself is not patient-centered unless it strengthens the patient-clinician relationship, promotes communication about things that matter, helps patients know more about their health, and facilitates their involvement in their own care. Similarly, advanced access scheduling could as likely lead to greater access to an overworked, uncaring functionary as it could to a familiar and caring presence in time of need. Now, it is important to check with 304 standards and 1218 Measurable elements (MEs) in 5th edition of JCIA (Joint Commission International Accreditation) hospital standards on the directive to care of patient into patient centered care.

Let's evaluate the ‘Care of Patients (COP)’ chapter of section-II in JCIA hospital standards under KISS (Keep it simple, stupid) principle and see how much it matches with patient centered care model. As we know, JCI accreditation is a collection of diverse innovations planned for a standardized system of healthcare evaluation as a response to the growing requests worldwide. Already 863 healthcare organizations are JCI accredited and many more are under pipeline. The aim is to provide an objective standard-based procedure for evaluating healthcare organizations throughout the world. The accreditation program is based on international standards which are compatible with local needs. Accreditation of an organization provides an obvious commitment for improving quality of safety, quality of patient care, ensuring safety surveillance and continuous activities for reducing risks which threaten patients and staff. It is considered a qualitative evaluation and efficient managerial tool, thus attracting the attention of organizations worldwide (JCI, 2002).

We have also observed that patients with the same health problems and care needs have a right to receive the same quality of care throughout the hospital to carry out the principle of “one level of quality of care requires that the department/service leaders plan and coordinate patient care.” In particular, services provided to similar patient populations in multiple departments or settings are guided by policies and procedures that result in their uniform delivery. In addition, the department/service leaders ensure that the same level of care is available each day of the week, and all work shifts each day. Those policies and procedures respect applicable laws and regulations that shape the care process and are best developed collaboratively. Uniform patient care is reflected in the following:

1. Access to and appropriateness of care and treatment do not depend on the patient’s ability to pay or the source of payment.
2. Access to appropriate care and treatment by qualified practitioners does not depend on the day of the week or time of day.
3. Acuity of the patient’s condition determines the resources allocated to meet the patient’s needs.
4. The level of care provided to patients (for example, anesthesia care) is the same throughout the hospital.
5. Patients with the same nursing care needs receive comparable levels of nursing care throughout the hospital.

Uniform patient care results in the efficient use of resources and permits the evaluation of outcomes of similar care throughout the hospital. These all discussed in ‘Care of Patients (COP)’ chapter, that contains twenty six (26) standards and one hundred ten (110) measurable elements (MEs), and nine (9) special topics of which are:

A. Care Delivery for All Patients
B. Care of High-Risk Patients and Provision of High-Risk Services
C. Recognition of Changes to Patient Condition
D. Resuscitation Services
E. Food and Nutrition Therapy
F. Pain Management
G. End-of-Life Care
H. Hospitals Providing Organ and/or Tissue Transplant Services (if applicable)
I. Transplant Programs Using Living Donor Organs (if applicable)

A. Care Delivery for All Patients: The patient care process is dynamic and involves many health care practitioners and can involve multiple care settings and departments and services. The integration and coordination of patient care activities are goals that result in efficient care processes, more effective use of human and other resources, and the likelihood of better patient outcomes. Thus, department/ service leaders use tools and techniques to better integrate and to coordinate care for their patients (for example, team-delivered care, multi-departmental patient rounds, combined care planning forms, integrated patient record, case managers). The patient’s record facilitates and reflects the integration and coordination of care. In particular, each practitioner records observations and treatments in the patient’s record. This section contains five (5) standards and nineteen (19) measurable elements (MEs) and the standards are:

1. Standard COP.1: Uniform care of all patients is provided and follows applicable laws and regulations.
2. Standard COP.2: There is a process to integrate and to coordinate the care provided to each patient
3. Standard COP.2.1: An individualized plan of care is developed and documented for each patient
4. Standard COP.2.2: The hospital develops and implements a uniform process for prescribing patient orders.
5. Standard COP.2.3: Clinical and diagnostic procedures and treatments performed, and the results or outcomes, are documented in the patient’s record.

Also, any results or conclusions from collaborative patient care team meetings or similar patient discussions are written in the patient’s record.  The plan of care outlines care and treatment to be provided to an individual patient. The plan of care identifies a set of actions that the health care team will implement to resolve or support the diagnosis identified by assessment. The overall goal of a plan of care is to achieve optimal clinical outcomes. The planning process is collaborative and uses the data from the initial assessment and from periodic re-assessments performed by physicians, nurses, and other health care practitioners to identify and to prioritize the treatments, procedures, nursing care, and other care to meet the patient’s needs. The patient and family are involved in the planning process with the health care team. The plan of care is developed within 24 hours of admission as an inpatient. Based on the re-assessment of the patient performed by the patient’s health care practitioners, the plan of care is updated as appropriate to reflect the evolving condition of the patient. The plan of care is documented in the patient’s record. The plan of care for a patient must be related to his or her identified needs. Those needs may change as the result of clinical improvement or new information from a routine re-assessment (for example, abnormal laboratory or radiography results), or they may be evident from a sudden change in the patient’s condition (for example, loss of consciousness). The plan of care is revised based on these changes and is documented in the record as notes to the initial plan, or they may result in a new plan of care. One method of developing care plans is to identify and establish measurable goals. Measurable goals can be selected by the responsible physician in collaboration with the nurse and other health care practitioners. Measurable goals are observable, achievable targets related to patient care and expected clinical outcomes. They must be realistic, specific to the patient, and time-based to provide a means for measuring progress and outcomes related to the plan of care. Examples of measurable, realistic goals include the following:

• The patient will resume and maintain an adequate cardiac output as indicated by a heart rate, rhythm, and blood pressure that are within normal limits.
• The patient will demonstrate proper self-administration of insulin injections prior to hospital discharge.
• The patient will be able to walk from his bed to the visitor lounge with a standard walker, bearing weight as tolerated on the affected leg.

It is noted that a single, integrated plan of care that identifies measurable goals expected by each health care practitioner is preferable. It is good practice for the plan of care to reflect individualized, objective, and measurable goals to facilitate reassessment and revision of the plan of care. Many patient care activities require a qualified individual to prescribe an order for that activity that must be documented in the patient record. Such activities may include, for example, orders for laboratory testing, administration of medications, specific nursing care, nutrition therapy, rehabilitative therapy, and the like. Patient care activities requiring orders are ordered by individuals qualified to do so. Such orders must be easily accessible if they are to be acted on in a timely manner. Locating orders on a common sheet or in a uniform location in patient records facilitates the carrying out of orders. Documented orders help staff understand the specifics of an order, when the order is to be carried out, and who is to carry out the order. Orders can be written on an order sheet that is transferred to the patient’s record periodically or at discharge, or a computerized order entry system may be used in hospitals that are using electronic patient records. Each hospital decides to

• which orders must be written/documented rather than verbal;
• which diagnostic imaging and clinical laboratory test orders must provide a clinical indication/rationale;
• any exceptions in specialized settings, such as emergency departments and intensive care units;
• who is permitted to prescribe orders; and
• where orders are to be located in the patient record.

Clinical and diagnostic procedures and treatments performed, and the results or outcomes, are documented in the patient’s record. Examples of such procedures and treatments include endoscopies, cardiac catheterization, radiation treatment, computerized tomography (CT) exams, and other invasive and noninvasive diagnostic procedures and treatments. Information about who requested the procedure or treatment and the reason for the procedure or treatment are included in the documentation.

B. Care of High-Risk Patients and Provision of High-Risk Services: Hospitals care for patients with a variety of health care needs. Some patients are considered high risk because of their age, their condition, or the critical nature of their needs. Children and the elderly are commonly placed in this group, as they frequently cannot speak for themselves, do not understand the care process, and cannot participate in decisions regarding their care. Similarly, the frightened, confused, comatose, or emergency patient is unable to understand the care process when care needs to be provided efficiently and rapidly. The section comprises one (01) standard and five (05) measurable elements (MEs) and the standard is:

1. Standard COP.3: The care of high-risk patients and the provision of high-risk services are guided by professional practice guidelines, laws, and regulations.

Hospitals also provide a variety of services, some of which are considered high risk because of the complex medical technology needed to treat a life-threatening condition (dialysis patients), the nature of the treatment (patients on life support), the potential for harm to the patient (restraint), or toxic effects of certain high-risk medications (for example, chemotherapy). Policies, guidelines, and procedures for managing the care of these patients are important tools for staff to understand and respond in a thorough, competent, and uniform manner. Hospital leadership is responsible for

• identifying the patients and services considered high risk in the hospital;
• using a collaborative process to develop guidelines and procedures for care; and
• training staff in implementing the guidelines and procedures.

Policies, guidelines, and procedures for care must be tailored to the particular at-risk patient population or high-risk service to be appropriate and effective in reducing the related risk. It is particularly important that the procedure identify

• how planning will occur, including the identification of differences between adult and pediatric populations, or other special considerations;
• the documentation required for the care team to work and to communicate effectively;
• special consent considerations, if appropriate;
• patient-monitoring requirements;
• special qualifications or skills of staff involved in the care process; and
• the availability and use of specialized medical technology.

When serving any of the high-risk patients or providing any of the high-risk services identified below, the hospital establishes and implements guidelines and procedures for the services provided for and the patients served. The high-risk services are for

1. emergency patients;
2. comatose patients;
3. patients on life support;
4. care of patients with a communicable disease;
5. care of immunosuppressed patients;
6. care of patients receiving dialysis;
7. care of patients in restraints;
8. care of patients receiving chemotherapy; and
9. care of vulnerable patient populations, including frail elderly, dependent children, and patients at risk for abuse and/or neglect.

Additional patients and services are included when they are represented in the hospital’s patient population and in the services it offers. Hospital leadership also identifies additional risk as the result of any procedures or plan of care (for example, the need to prevent deep vein thrombosis, decubitus ulcers, and ventilator-associated infections in patients on life support; neurological and circulatory injury in restrained patients; blood exposure in dialysis patients; central line infections; and falls). Such risks, when present, need to be addressed and prevented by educating staff and developing appropriate policies, guidelines, and procedures. The hospital uses measurement information to evaluate the services provided to high-risk patients and integrates that information into the hospital’s overall quality improvement program.

C. Recognition of Changes to Patient Condition: Staffs who do not work in critical care areas may not have adequate knowledge and training to assess and monitor patients with critical conditions. However, a significant number of patients outside of critical care areas experience critical inpatient events. Often, a patient will exhibit early warning signs (for example, a worsening of vital signs or a subtle change in neurological status) shortly before experiencing significant clinical decline, resulting in a major event. The literature identifies physiological criteria that can assist staff in early detection of deteriorating patients. A majority of patients who experience cardiopulmonary or respiratory arrest demonstrate clinical deterioration prior to arrest. When staffs are able to identify these patients early and request additional assistance from specially trained individuals, clinical outcomes improve. This section includes one (1) standard and four (4) measurable elements (MEs) and the standard is:

1. Standard COP.3.1: Clinical staffs are trained to recognize and respond to changes in a patient’s condition.

All clinical staffs require education and training to provide the knowledge and skills to recognize and intervene when patient assessments identify physiological signs that are outside of the normal range, indicating a potential for patient deterioration. Early response to changes in a patient’s condition is critical to potentially preventing further deterioration. Hospitals that develop a systematic approach to early recognition and intervention of patients whose condition is deteriorating may reduce cardiopulmonary arrests and patient mortality.

D. Resuscitation Services: Resuscitation services can be defined as clinical interventions for the emergent care of patients experiencing a critical, life-threatening event, such as cardiac or respiratory arrest. When a cardiac or respiratory arrest occurs, the immediate initiation of chest compressions or respiratory support may mean the difference between life and death or, at the very least, may help avoid potentially serious brain damage. This section covers two (02) standards and six (06) measurable elements (MEs) and standards are:

1. Standard COP.3.2: Resuscitation services are available throughout the hospital.
2. Standard COP.3.3: Clinical guidelines and procedures are established and implemented for the handling, use, and administration of blood and blood products

Successful resuscitation of patients in cardiopulmonary arrest is dependent on critical interventions, such as early defibrillation and accurate implementation of advanced life support. These services must be available to all patients, 24 hours a day, every day. Essential to providing these critical interventions is the quick availability of standardized medical technology, medications for resuscitation, and staff properly trained in resuscitation. Basic life support must be implemented immediately upon recognition of cardiac or respiratory arrest, and a process must be in place for providing advanced life support in fewer than 5 minutes. This could include reviews of actual in-hospital resuscitations as well as mock cardiac arrest response training. Resuscitation services available within the hospital, including medical technology and properly trained staff, must be based on clinical evidence and the population served (for example, if the hospital has a pediatric population, medical technology for pediatric resuscitation must be available). It is also noted that all areas of the hospital includes any areas where treatment and services are provided, including treatment or diagnostic areas in separate buildings on the hospital campus. Blood must be administered in accordance with standards of practice and in a consistent manner in order to ensure the safety of the recipient. Therefore, clinical guidelines and procedures describe the process for

1. procurement of blood from the blood bank or blood storage area;
2. patient identification;
3. blood administration;
4. monitoring of the patient; and
5. identification and response to signs of potential transfusion reactions.

An individual with the education, knowledge, and expertise to oversee the blood and blood products administration ensures that processes, procedures, and clinical guidelines for transfusions are defined and implemented.

E. Food and Nutrition Therapy: Appropriate food and nutrition are important to patients’ well-being and recovery. Food choices take into consideration the patient’s age, cultural and dietary preferences, and planned care, which may include special dietary needs such as low cholesterol, diabetic diet, and clear liquids, depending on the patient’s diagnosis. This section covers two (02) standards and eight (08) measurable elements (MEs) and standards are:

1. Standard COP.4: A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, is available.
2. Standard COP.5: Patients at nutrition risk receive nutrition therapy

The patient participates in planning and selecting foods, and the patient’s family may, when appropriate, participate in providing food, consistent with cultural, religious, and other traditions and practices and compatible with the patient’s diagnosis. Based on the patient’s assessed needs and plan of care, the patient’s physician or other qualified caregiver orders food or other nutrients for the patient. When the patient’s family or others provide food to the patient, they are educated about foods that are contraindicated according to the patient’s care needs and plans, including information about any medications associated with food interactions. When possible, patients are offered a variety of food choices consistent with their nutritional status. On initial assessment, patients are screened to identify those patients who may be at nutritional risk. These patients are referred to a nutritionist for further assessment. When it is determined that a patient is at nutritional risk, a plan for nutrition therapy is developed and carried out. The patient’s progress is monitored and recorded in his or her record. Physicians, nurses, the dietetics service, and, when appropriate, the patient’s family, collaborate to plan and to provide nutrition therapy.

F. Pain Management: Pain can be a common part of the patient experience and may be associated with the condition or illness for which the patient is being treated. Pain may also be an expected part of certain treatments, procedures, or examinations. As part of care planning, patients are informed about the likelihood of pain when it is an anticipated effect from treatments, procedures, or examinations and what options for pain management are available. Whatever the origin of pain, unrelieved pain has adverse physical and psychological effects. This section covers one (01) standards and eight (08) measurable elements (MEs) and standard is:

1. Standard COP.6: Patients are supported in managing pain effectively.

Thus, patients in pain have the right to appropriate assessment and management of pain. Based on the scope of services provided, the hospital has processes to assess and to manage pain appropriately, including

• identifying patients with pain during initial assessment and reassessments;
• providing information to patients about pain that may be an expected result of treatments, procedures, or examinations;
• providing management of pain, regardless of the origin of pain, according to guidelines or protocols and in conjunction with patient goals for pain management;
• communicating with and educating patients and families about pain and symptom management in the context of their personal, cultural, and religious beliefs; and
• educating health care practitioners about pain assessment and management

G. End-of-Life Care: Patients who are approaching the end of life require care focused on their unique needs. Dying patients may experience symptoms related to the disease process or curative treatments or may need help in dealing with psychosocial, spiritual, and cultural issues associated with death and dying. Their families and caregivers may require respite from caring for a terminally ill family member or help in coping with grief and loss. This section covers two (02) standards and eight (08) measurable elements (MEs) and standards are:

1. Standard COP.7: The hospital addresses end-of-life care.
2. Standard COP.7.1: Care of the dying patient optimizes his or her comfort and dignity

The hospital’s goal for providing care at the end of life considers the settings in which care or service is provided (such as a hospice or palliative care unit), the type of services provided, and the patient population served. The hospital develops processes to manage end-of-life care. These processes are:

• ensure that symptoms will be assessed and appropriately managed;
• ensure that terminally ill patients will be treated with dignity and respect;
• assess patients as frequently as necessary to identify symptoms;
• plan preventive and therapeutic approaches to manage symptoms; and
• educate patients and staff about managing symptoms.

Patients who are dying have unique needs for respectful, compassionate care. To accomplish this, all staffs are made aware of the unique needs of patients at the end of life. Concern for the patient’s comfort and dignity should guide all aspects of care during the final stages of life. The hospital evaluates the quality of the end-of-life care provided by evaluating family and staff perceptions of the care provided. End-of-life care provided by the hospital includes:

1. providing appropriate treatment for any symptoms according to the wishes of the patient and family;
2. sensitively addressing such issues as autopsy and organ donation;
3. respecting the patient’s values, religion, and cultural preferences;
4. involving the patient and family in all aspects of care; and
5. responding to the psychological, emotional, spiritual, and cultural concerns of the patient and family
6. The hospital ensures appropriate care of those in pain or dying by

• taking interventions to manage pain and primary or secondary symptoms;
• preventing symptoms and complications to the extent reasonably possible;
• taking interventions that address patient and family psychosocial, emotional, and spiritual needs regarding dying and grieving;
• taking interventions that address patient and family religious and cultural concerns; and
• involving the patient and family in care decisions.

H. Hospitals Providing Organ and/or Tissue Transplant Services (if applicable): Transplantation of organs is often a lifesaving procedure, and organ and tissue transplants are sometimes the only options for treatment of a wide range of diseases. Recent advances in transplantation have led to a greater success rate for transplanted organs and tissues. However, transplantation is not free from risk. Transmission of infections from the donor to the recipient is a well-documented safety concern. Diseases with documented transmission from infected donors subsequent to transplant include, to name a few, HIV, hepatitis B and C, and Creutzfeldt-Jakob disease (CJD). Recipients may also contract bacterial or fungal infections through contamination during transportation, storage, or handling. Leadership’s commitment to creating a culture conducive to organ and tissue donation can have significant impact on the overall success of the hospital’s organ and tissue procurement efforts. These standards address the hospital’s organization-wide responsibilities for organ and tissue donation and procurement. This includes any individual who has been determined medically suitable for donation by the organ-procurement organization. If the hospital has the necessary resources to support the recovery of organs and tissues after cardiac death, non–heart-beating donors are included in the organ procurement effort. The section covers eight (08) standards and thirty three (33) measurable elements (MEs) and standards are:

1. Standard COP.8: The hospital’s leadership provides resources to support the organ/tissue transplant program.
2. Standard COP.8.1: A qualified transplant program leader is responsible for the transplant program
3. Standard COP.8.2: The transplant program includes a multidisciplinary team that consists of people with expertise in the relevant organ-specific transplant programs.
4. Standard COP.8.3: There is a designated coordination mechanism for all transplant activities that involves physicians, nurses, and other health care practitioners
5. Standard COP.8.4: The transplant program uses organ-specific transplant clinical eligibility, psychological, and social suitability criteria for transplant candidates.
6. Standard COP.8.5: The transplant program obtains informed consent specific to organ transplantation from the transplant candidate.
7. Standard COP.8.6: The transplant program has documented protocols (or procedures) for organ recovery and organ receipt to ensure the compatibility, safety, efficacy, and quality of human cells, tissues, and organs for transplantation.
8. Standard COP.8.7: Individualized patient care plans guide the care of transplant patients

The organ/tissue transplant program requires staff with specialized education and training and other resources in order to provide safe, high-quality care. Other essential resources include supplies, patient rooms with ventilation required for the type of transplant procedure (for example, positive pressure ventilation), required pharmaceuticals for the type of transplant procedure, laboratory testing to ensure that tissue/organs are not contaminated, and other resources as identified by the program service leader. In addition, resources related to information management systems are necessary to assist with the collection of data associated with risks, outcomes, and other information that support the quality of the transplant program. The responsibility of a hospital offering organ and tissue transplant services is to provide safe, high-quality care to transplant donors and recipients. A key element of the infrastructure is an individual(s) responsible for oversight of the organ/tissue transplant program. Acting on a full-time or part-time basis, this individual(s) provides that oversight as part of his or her assigned responsibilities or job description. This individual(s) is qualified in transplant management through education, training, experience, licensure, and/or certification. The success of a transplant program and positive outcomes for transplant recipients and living donors as well are dependent on a team of health care providers who have clinical knowledge and expertise in organ-specific transplantation. The nursing, psychological, pharmacological, and nutritional needs of an organ recipient and a living organ donor are unique. As related to the type of transplant, a multidisciplinary team consists of individuals from

• medicine;
• nursing;
• nutrition;
• pharmacology;
• social services; and
• psychological services.

This team should have the qualifications, training, and experience to provide care and services to transplant recipients and living donors. An important component in ensuring safe, high-quality care through all phases of the donor/recipient process is identifying an individual with overall responsibility for coordination and continuity of the live donor’s and recipient’s care. This individual may be a physician, registered nurse, or other qualified health care professional. There are multiple areas for consideration when a decision needs to be made about allocating organs to recipients. Consideration may be given to the imminent need of the patient for a transplant, the benefit the patient may gain from the transplant, the availability of alternative treatments, the expected improvement in the patient’s quality of life, and the amount of resources required for successful treatment. Because human organs and tissues available for transplant are limited, criteria for recipient selection are developed. Criteria for transplant recipient selection helps identify the most appropriate patient and limits the potential for bias. Thus, criteria for access to organs and tissues are defined in a transparent manner, based on an objective evaluation of medical needs. In addition, there are organ-specific criteria that must be taken into account in the decision for allocating an organ. For example, the viability of an organ outside of the body varies from organ to organ. Thus consideration must be given to the length of time it may take for an organ to reach the recipient. To consent, a patient must be informed of those factors related to the planned care required for an informed decision. Factors that could affect the success of the graft or the candidate’s health as a recipient include, but are not limited to,

1. the donor’s history;
2. condition of the organ(s) used;
3. age of the organ(s); and
4. the potential risk of contracting infectious disease(s) if disease(s) cannot be detected in an infected donor.

In addition, to reduce the risk of organ rejection, the transplant surgeon must ensure the compatibility of the donor organ(s) to the recipient. The most frequently used tests for compatibility include blood typing and cross-matching and tissue typing. The transplant surgeon ensures that testing for compatibility occurs before organ recovery and organ transplantation takes place. There may be psychological, ethical, financial, and other factors that are unique to the transplant patient than for other patients, such as the need for immunosuppressive medications and the projected survival rate. The patient needs to be informed of all special considerations as part of the consent process. The transplant program also follows the hospital’s policy for informed consent as well as local and regional laws and regulations.

I. Transplant Programs Using Living Donor Organs (if applicable): The growing demand for and limited supply of organs from deceased donors have resulted in increased efforts to promote live organ donation. Living donor standards for the selection of suitable candidates for donation, informed consent, and care following the donation do not universally exist. Living donors face difficult decisions and are at potential risk for lifelong complications and should not feel coerced or pressured into organ donation. To help with decisions and to ensure that the living donor’s rights are protected, an individual with knowledge of living organ donation, transplantation, medical ethics, and informed consent must be identified. This section comprises of four (04) standards and nineteen (19) measurable elements (MEs) and standards are:

1. Standard COP.9: Transplant programs that perform living donor transplantation protect the rights of prospective or actual donors.
2. Standard COP.9.1: Transplant programs performing living donor transplants obtain informed consent specific to organ donation from the prospective living donor
3. Standard COP.9.2: Transplant programs that perform living donor transplants use clinical and psychological selection criteria to determine the suitability of potential living donors.
4. Standard COP.9.3: Individualized patient care plans guide the care of living donors

The growing demand for and limited supply of organs from deceased donors have resulted in increased efforts to promote live organ donation. Living donor standards for the selection of suitable candidates for donation, informed consent, and care following the donation do not universally exist. Living donors face difficult decisions and are at potential risk for lifelong complications and should not feel coerced or pressured into organ donation.

Overall Required Written Policies (Including Those Required in English) in COP: The standards listed in the tables identify a requirement for six (06) written documents for COP. In some cases, that document is in the form of a policy and procedure. In other cases, the document is less formal but addresses the issue identified in the standard. In many cases, a number of standards requirements or MEs can be combined into one policy and procedure. Hospitals may find it useful to group all related policies and procedures. The surveyor(s) may not need to review all these documents in detail. However, to facilitate the review, it is best to gather all of the documents into one book or identify each document by the corresponding standard number(s) if they are part of a larger document. Some of these documents need to be provided to JCI surveyors in English, and these documents are indicated in the “In English?” column in the tables. Other documents do not need to be translated. For non-English documents, the survey team will have one member able to read the documents, or alternatively, the survey team may request that one or more individuals be available to describe the contents of the document and answer questions concerning the document.

Closed Patient Medical Record Review on COP: This session is held to validate the hospital’s compliance with the documentation track record started with 4 months for initial surveys and 12 months for triennial surveys.

• The survey team leader may request 5 to 10 closed records for review. The records will be requested if the surveyor(s) wants to validate the hospital’s documentation track record (4-month or 12-month) and/or to ensure compliance with documentation or patient care process requirements due to situations or information identified during the tracer activities.
• The survey team will also indicate the time period for selecting the records, typically the past 4 or 12 months. Hospital staff should acquaint the survey team with the hospital’s practice and expectation regarding the completion of a patient record following discharge of the patient.
• For the Closed Patient Medical Record Review, hospital leaders should provide one staff member with a translator (if needed) for each surveyor involved in the Closed Patient Medical Record Review. To assist the surveyor(s), the selected staff person(s) should be knowledgeable about the medical record and the clinical care processes. Academic medical center hospitals are encouraged to include residents and fellows in the record review.
• The surveyor(s) will review the selected records with the assistance of the hospital representative, as needed, to complete the form. One column of the form is completed for each record reviewed. If more than five records are reviewed, the surveyor(s) will use another form.
• For each documentation requirement, the surveyor(s) will check “Y” (yes) on the form to indicate that the required element is present, “N” (no) if the element is not present, or “NA” if the element is not applicable to that patient’s record.
• The survey team aggregates the completed review forms to score the standards. The findings from the active or open review of patient records are integrated into aggregation and scoring.
• For COP, the required seven (07) points listed in the table will be checked in medical records system by surveyor to validate COP standards.

Patient-centered care is the ultimate care of patient for 21st century healthcare domain. How to establish such services? Here are the 10 patient-centered care guiding principles described by Tamera Parsons, vice president of quality and patient safety at Mountain States Healthcare Alliance (MSHA):

1. All team members are considered caregivers: Under this principle, everyone in the workforce, from housekeeping staff to the CEO, is part of patients' care experience. Regardless of one's role, each person is expected to put the patient first. To create a patient-centered culture, MSHA has patient-centered care training for new employees. "They learn from day one that all team members are caregivers," Ms. Parsons says. In addition, MSHA recognizes employees through thank you notes and awards for demonstrating patient-centered care principles.
2. Care is based on continuous healing relationships: This principle reinforces a focus on the continuum of care for patients rather than episodes of care. "We're here to not only provide care, but also to provide healing — a more personal level of healthcare," Ms. Parsons says.
3. Care is customized and reflects patient needs, values and choices: The principle of customizing care recognizes that each patient is different and may have different needs and preferences. In addition to customizing the care plan for each patient, MSHA works to make the environment comfortable to individual patients. For example, one patient may want music in the room, where another patient may not. "It allows the patient's individuality to be a component of care," Ms. Parsons says."
4. Knowledge and information are freely shared between and among patients, care partners, physicians and other caregivers: In a patient-centered environment, all members of the care team — including the patient — need to be aware of the patient's status and care plan. "If the patient is going to be the center of care, [he or she] absolutely needs to be informed and part of the decision-making," Ms. Parsons says.
5. Care is provided in a healing environment of comfort, peace and support: Part of a patient-centered culture is the environment. MSHA has several features that create a healing environment for patients, including music, healing gardens, soothing color schemes and pet therapy programs. The hospitals also ensure rooms have pleasing scents, such as lavender or the smell of baked cookies, according to Ms. Parsons.
6. Families and friends of the patient are considered an essential part of the care team: MSHA recognizes that family and friends are essential supports for the patient's healing process. Family and friends support patients not only emotionally, but also physically, as they can help patients understand physicians' instructions. In the health system's Very Important Partner program, patients identify an individual to listen to care information with them. "Patients [may be] in a state of discomfort and pain or fear, and don't always hear information, so it [allows] a trusted family member or friend identified by the patient to participate in the sharing of information and guidance we give before sending patients home or to the next level of care," Ms. Parsons says.
7. Patient safety is a visible priority: Making patient safety a visible priority demonstrates the organization's commitment to patient care. MSHA implements policies and procedures to enforce patient safety best practices. For example, the system had a campaign around employee immunization and hand hygiene. MSHA also has a balanced scorecard called the blue print. The scorecard tracks the system's performance in key areas, such as heart failure, pneumonia and surgical care.
8. Transparency is the rule in the care of the patient: This principle recognizes that true patient-centered care requires transparency between providers and patients and among providers. Providers should be "upfront and honest with information so [patients] can make informed decisions with us," Ms. Parsons says. One way MSHA supports transparency is by posting its quality and safety performance on its website.
9. All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient: All processes at MSHA, even those that don't involve patients, should be performed from a "patient-value" perspective," Ms. Parsons says. For example, she says the coding and billing process is done from the perspective of the patient; staff has worked to make bills clear and easy to understand for patients.
10. The patient is the source of control for their care: A core tenet of patient-centered care is that the patient controls his or her care. "Making patients the source of control of their care is the result of effective deployment of all other guiding principles," Ms. Parsons says. "To be the source of control, you have to have transparency and share information, create an environment that allows the patient to heal and focus work on the patient. After discharge, patients can still have a degree of control by participating in a patient advisory group that meets regularly at each MSHA facility to provide input on how the system can improve care and become more patient-centered. The groups are composed of six to 12 patients who provide input on specific care models, such as diabetes programs. Soliciting suggestions from those on the receiving end of healthcare gives patients some control over future healthcare services and helps MSHA continue to put patients first in their decisions.

These practical guiding principles are directive for other healthcare service providers to transform the services into Patient centered care. Putting patient's first is not a marketing glimpse but it is a true vision for the healthcare to make service available for the patient. One good step is already taken by most of the hospital to introduce multi-disciplinary team round to single patient and establish the care plan through team approach. Even sometimes primary physician called a group meeting for certain critical patients with multi-specialties related physicians to streamline care plan of the patient. Now the new demand to include more non-physician members like nutrition consultant, clinical pharmacist, physiotherapist, nurse manager, patient family or visitor into that group meeting to put it truly a patient centered care model. So, putting patients first requires more than world-class clinical care – it requires care that addresses every aspect of a patient’s encountered in a facility, including the patient’s physical comfort, as well as their educational, emotional, and spiritual needs.