JCAHO Standards

JCAHO STANDARDS

Hospital | Early Referral | JCAHO Standards | Medicare | HIPAA

New Mexico Donor Services can assist your hospital to prepare for Joint Commission for the Accreditation of Hospitals & Healthcare Organizations (JCAHO) review.

Here's a quick look at the items that should be in place:

Current copy of Hospital and New Mexico Donor Services agreement
Current copies of all hospital policies relating to organ donation and brain death
List of all organ donations and documentation of all donation referrals for the review period
Documentation of all donation education in-service programs
Death record review data and summary
Hospital's Organ Donor Conversion Rate (# of organ donors / # of eligible donors) can be accessed at www.USTransplant.org

Starting in 2005, JCAHO surveyors are focusing on a hospital's Organ Donation Conversion Rates. Health & Human Services has set a goal for hospital conversion rates to be 75%.

Hospitals Only: effective July 1, 2005 - Organ Donation and Procurement - Surveyors will evaluate organ procurement issues based upon the conversion rate:

Tier 1 (61%-100% conversion rate) survey limited to discussion with leaders in the Opening Conference.
Tier 2 (41%-60% conversion rate) in addtion to discussion with leaders, surveyors will address issues during tracer activities. Topics may include the process to notify family of potential donors of its options to donate organs, tissues, or eyes; education; or program effectiveness.
Tier 3 (0-10% conversion rate) in addition to discussion in the Opening Conference, tracers will focus on organ procurement through the selection of charts involving the ED and ICU, and at least 1 death chart will be reviewed to address Organ Procurement Organization notification, response and outcome. The topic is also addressed in the Data Use System Tracer.