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The Joint Commission Big Book of Policies and Procedures for Hospitals, Volume 1 cover
U.S. Standards

The Joint Commission Big Book of Policies and Procedures for Hospitals, Volume 1 (PDF site license)

ISBN# 9781635850482

An authoritative collection of sample P&Ps required by Joint Commission hospital accreditation standards.  Downloadable and customizable.  Save time and effort!

Release Date:  February 25, 2019. 236 pages. Site license.

Terms and Conditions:
An ebook is copyrighted by The Joint Commission and therefore protected by United States copyright law. You are expected to comply with the terms of your particular purchased license, as explained here:
PDF Site License - A PDF site license entitles you to share this electronic book with others in your organization only, either by posting to a secure intranet site or by providing other means of secure access. For users who do not work within one facility, consider a system license. Please contact JCR Customer Service (877.223.6866 option 1) for pricing of a system license.
Please Note: The above license allows for secured electronic access; it does not allow for widespread printing and distribution of the ebook in hard copy format, even within a facility or system. If The Joint Commission becomes aware of any infringement on its copyrighted content, it reserves the right to pursue legal action against any or all parties not complying with the terms of this ebook license.

Product Description

Product Description

Health care organizations are continually challenged to keep pace with evolving regulations, standards, and practices—and to review and update their policies and procedures to match.
The Joint Commission Big Book of Policies and Procedures for Hospitals, Volume 1 introduces the purpose of policies and procedures (P&Ps) and provides a standardized development process and multiple templates. This contextual information is very important, especially for those new to accreditation. The bulk of the book features dozens of sample P&Ps--all downloadable and adaptable to your hospital’s particular needs. We made sure to include sample policies, procedures, and plans that match those required by Joint Commission hospital standards. Get P&Ps correlated to nearly every standards chapter, including Environment of Care, Infection Prevention and Control, Medication Management, National Patient Safety Goals, and Rights and Responsibilities of the Individual, among others. The P&Ps you'll see are only samples. They are not meant to be used verbatim but rather are designed to show you what policies and procedures look like when you apply the rigorous strategies introduced in the book.
This Big Book is not a complete and comprehensive collection of the policies and procedures your hospital needs. Rather, it is a preliminary collection to provide guidance on a wide range of standards topics. Future volumes will be released in coming years to allow you to continue to grow your collection of P&Ps.
The Joint Commission Big Book of Policies and Procedures, Volume 1 is available in electronic format as a site license so that everyone in your hospital can use and access these essential materials.
Key Topics:
  • The role of policies, procedures, and plans in quality improvement and patient safety
  • Continuous standards compliance and survey readiness
  • Required policies and procedures for Joint Commission hospital accreditation
  • Physical environment
  • Infection prevention and control
  • Medication management
  • National Patient Safety Goals
  • Provision of care
  • Rights and responsibilities of the individual
Key Features:
  • Downloadable and customizable policies and procedures on a wide range of topics 
  • Explanation of how to develop and manage policies and procedures
  • Checklist of all Joint Commission requirements that call for written policies, procedures, protocols, and plans
  • Trusted content reviewed by subject matter experts from The Joint Commission
  • Adaptable, expandable policy inventory template
  • Standardized templates for writing policies, procedures, and plans
  • Checklist and scoring rubric to help guide the evaluation of your policies and procedures to ensure they contain key elements
Standards: Various accreditation standards
Setting: Hospital
Key Audience:
  • Accreditation professionals
  • Performance improvement specialists
  • Hospital leaders and administrators who are responsible for developing, managing, updating, and communicating policies and procedures
  • Clinical leadership
  • Infection control practitioners
  • Medication safety officers
  • Patient safety officers
  • Human resources professionals
  • Health care facility managers
Table of Contents

Table of Contents

DRAFT Table of Contents
Section 1—Leadership
Code of Conduct Policy
Conflict of Interest Policy
Section 2—Staffing and Medical Staff
Focused Professional Practice Evaluation Policy
Ongoing Professional Practice Evaluation Policy
Medical Staff Bylaws, Rules, and Regulations Policy
Temporary Privileges Policy
Section 3—Care of the Patient
Pre-Procedure Verification Procedure
Surgical Site Marking Alternative Procedure
Surgical Time-Out Procedure
Clinical Alarm Management Policy
Initial Assessment Procedure
Radiological Imaging Safety Policy
Electroconvulsive Therapy Policy
Discharge Planning Policy
Blood Handling Policy
Patient Rights Policy
Informed Consent Policy
Advance Directives Policy
Restraint and Seclusion Policy
Mistreatment and Misappropriation Prohibition Policy
Section 4—Health Information and Technology
Information Systems Interruption Management Plan
Confidentiality and Security of Health Information Policy
Medical Record Entry Authentication Policy
Medical Record Timeliness Policy
Section 5—Infection Prevention and Control
Infection Control During Construction Policy
Infectious Disease Outbreak Response Procedure
Hand Hygiene Policy
Section 6—Medication Management
Accessibility of Patient Information Policy
Medication Control Policy
Medication Orders Policy
Recalled Medication Policy
Automatic Dispensing Cabinets Override Review Policy
Antimicrobial Stewardship Procedure
Anticoagulation Management Policy
Central Venous Catheter Management Procedure
Section 7—Testing, Transplants, and Imaging
Opportunities for Asystolic Recovery of Organs for Donation Policy
Family Notification of Organ Donation Procedure
Affiliated Organ Procurement Organization Policy
Specimen Management Policy
Waived Testing Policy
Section 8—The Physical Environment
Environment of Care Plan
Active Threat Response procedure
Smoke-Free Policy
Hazardous Material Spill Response Procedure
Fire Response Plan
Medical Equipment Failure Response Procedure
Providing Emergency Power to Medication Dispensing Equipment Policy
Compressed Gas Cylinder Management Policy
Emergency Operations Plan
Interim Life Safety Measures Policy
Appendix: Required Plans and Procedures


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Conflict of Interest

Joint Commission Resources maintains control over all continuing education content provided to ensure content integrity and minimize educational bias. All education planners, faculty, content reviewers, authors, and others involved with continuing education activities disclose influencing relationships, or lack thereof, including financial or commercial interests. The Joint Commission ensures the accuracy and consistency of the application of accreditation criteria to ensure appropriateness of relationships and affiliations that may impact educational content.

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