Action Alerts

Hospital Based Ambulatory Care Advance Directives
November 2004

JCAHO updated the CAMH Manual August 3, 2004. The “Ethics, Rights, and Responsibilities Chapter”, standard, RI.2.80 states, “The hospital addresses the wishes of the patient relating to end-of-life decisions”.

The Elements of Performance, 10, 11, and 12 are specific to ambulatory care settings.

Element #11 states, “For Outpatient Hospital Settings: The policies are communicated to patients and families when asked about or as appropriate to the care, treatment, and services provided.”.

This measured Element #11 challenges a hospital to determine what ambulatory procedures (such as invasive cardiac catheterization or cardiac rehabilitation services) are included in a policy which outlines when advance directives are identified and offered in the ambulatory setting.

Please be advised that JCAHO surveyors are now asking hospitals what their policies are in determining whether outpatients have advance directives including do not resuscitate orders and providing the outpatients with information to form such advance directives. Be sure your advance directive policy addresses applicability of providing advance directive information in the ambulatory setting.

Questions?

Please call QMCG at (614) 227-4848. This timely and complimentary information is brought to you by the Quality Management Consulting Group, Ltd. (QMCG).