Language/Interpreter Policy

Language Interpreter

Notice of Available Language Services

Interpreter Services are available 24/7 at no cost to our non-English speaking, hard-of-hearing, and deaf patients and families. Services include in-person, video, and over-the-phone medical interpreters in the preferred languages of our communities.










See below for the language/interpreter policy of the location you wish to visit.

Long Beach Memorial / Community Hospital Long Beach

Language Access For Limited English Proficient (LEP) And Hearing Impaired Patients And Families

AUTHORITY:

Health and Safety Code Section 1259; Joint Commission Comprehensive Accreditation Manual for Hospitals: Ethics, Rights, and Responsibilities.

BACKGROUND:

Long Beach Memorial (LBM) serves a significant population of Limited English Proficient (LEP) patients and their families. Ensuring that LEP and hearing impaired patients can effectively provide hospital staff with a clear communication of their medical condition and history and understand the provider’s assessment of their medical condition and treatment options is essential to the provision of quality patient care.

PURPOSE:

The purpose of the Language Access Policy is twofold. (1) To ensure that LEP and hearing impaired patients and surrogate decision-makers understand their medical conditions and treatment options; (2) To provide quality patient care for LEP and hearing impaired patients through effective communication and collaboration.

DEFINITIONS:

Assessed Bilingual Employee – Bilingual employees who have been deemed linguistically qualified to provide basic interpreting services in their department through interpreter training and/or assessment. Family conferences and sensitive or end-of-life discussions are outside the scope of assessed bilingual employees and should be referred to the Interpreter Services Department.

Bilingual Medical Provider – A physician, registered nurse, or clinician who identifies him or herself as bilingual, fluent in a language other than English, may communicate directly with their own patients in the non-English language, however they should not act as interpreters unless deemed qualified to do so

Frequently Encountered Languages of LBM - The governing body of LBM shall, at its discretion, add or remove additional languages from the designation of Frequently Encountered Languages based on the changing demographics of the hospital system’s patients and service area. The Frequently Encountered Languages of LBM at this time are: Spanish, Cambodian (Khmer), Arabic, Korean, and Vietnamese.

Healthcare Interpreter - A staff interpreter who has 1) been trained in healthcare interpreting, 2) adheres to the professional code of ethics and protocols of healthcare interpreters, 3) is knowledgeable about bilingual medical terminology, and 4) can accurately and completely render communication from one language to another. Healthcare Interpreters may interpret for all departments.

Hearing Impairment – Any degree of diminished ability to apprehend sound; this includes total deafness.

Interpreting – The oral or signed rendering of one language into a second language and vice versa to facilitate the exchange of communication between two or more persons speaking different languages. Interpreting requires triadic (group of three) communication involving the healthcare interpreter, patient, and provider.

Limited English Proficient (LEP) – A limited ability or the inability to speak, read, write, or understand the English language at a level that permits the person to interact effectively with health care providers or social service agencies.

Reasonable Time - Defined to include a limit of 30 minutes for the provision of interpreter services for LEP patients/patient representatives who require language assistance. This time shall be marked from the time interpreter service is requested until the time interpreter service is available. If in-house staff interpreters are unavailable, all departments/employees should use Language Line Telephone Interpreting service for immediate language assistance.

Sign Language – Defined by the National Association for the Deaf as a visual language used by the deaf. With signing, the brain processes linguistic information through the eyes. The shape, placement, and movement of the hands, as well as facial expressions and body movements, all play important parts in conveying information. Sign language is not a universal language -- each country has its own sign language, and regions have dialects, much like the many languages spoken all over the world.

Telephone Interpreting - A form of remote interpreting that offers the delivery of interpreter services through telephone technology. Telephone interpreting allows for an audio connection between the patient, physician (or other healthcare provider) and interpreter. Telephone interpreting is best conducted with auxiliary telephone equipment such as a dual headset or speakerphone to allow for the most effective communication among the three parties.

Threshold Languages - Languages that meet the following standards, “A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their preferred language as other than English, and that meet a numeric threshold of 3,000; or, a population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their preferred language as other than English and who meet the concentration standards of 1,000 in a single ZIP code or 1,500 in two contiguous ZIP codes.1 The Threshold Languages of LBM at this time are: Spanish and Cambodian (Khmer).

Translation – Defined in the California Standards for Healthcare Interpreters: Ethical Principles, Protocols, and Guidance on Roles and Intervention as the conversion of a written (source) text into a written (target) text in a second language corresponding to and equivalent in meaning to the text in the first (source) language.1

Video Remote Interpreting – Real-time video and audio access to interpreter services through videoconferencing technology.

Vital Documents –Vital Documents shall include, but are not limited to, documents that contain information for accessing LBM hospital services and/or benefits. The following types of documents are examples of Vital Documents: 1) Consents; 2) Advance Directives; 3) complaint forms; 4) “notices pertaining to the denial, reduction, modification or termination of services and benefits, and the right to file a grievance or appeal;”2 5) Patient Rights; and, 6) other notices advising LEP persons of free language assistance, or applications to participate in a program or activity or to receive benefits or services.3

SCOPE AND RESPONSIBILITY:

A. Scope: This policy applies throughout Long Beach Memorial.

B. Responsibility: Implementation of this policy is the responsibility of employees and contracted personnel having contact with patient, family, and/or significant others and leadership and team of the Interpreter Service Department.

POLICY:

Policy on the Provision of Medical Services to Patients/Surrogate Decision-Makers Needing Language Assistance:

  1. LEP and hearing impaired patients/surrogate decision-makers shall be advised of their right to have interpreter services provided in their preferred language within a reasonable time, at no charge to them.

  2. Effective communication is important in every area of hospital communication, but LBM prioritizes communication in the provision of medical, nursing and ancillary services, where patient safety, medical error, and ability to understand treatment options are affected. The following types of encounters and procedures require the use of an interpreter if the provider does not speak the patient/surrogate decision maker’s preferred language, these include, but are not limited to:
    a. Providing clinic and emergency medical services;
    b. Obtaining medical histories;
    c. Explaining any diagnosis and plan for medical treatment;
    d. Discussing any mental health issues or concerns;
    e. Explaining any change in regimen or condition;
    f. Explaining any medical procedures, tests or surgical interventions;
    g. Explaining patient rights and responsibilities;
    h. Explaining the use of seclusion or restraints;
    i. Obtaining consent;
    j. Providing medication instructions and explanation of potential side effects;
    k. Explaining discharge plans;
    l. Discussing issues at patient and family care conferences and/or health education sessions;
    m. Discussing Advance Directives;
    n. Discussing end of life decisions; and,
    o. Obtaining financial and insurance information.

  3. The policy of LBM shall be to provide patients and surrogate decision-makers requiring language assistance with medical care in their preferred language spoken, or a healthcare interpreter provided by LBM. Healthcare Interpreters employed by LBM shall be tested annually and evaluated to ensure that the interpreting provided for healthcare services is comprehensive and accurate. It is not only ethically inappropriate for minor children to act as healthcare interpreters, but they also lack the training, skills and competencies.4 Also, family members are not to be asked to interpret as this violates HIPAA privacy regulations. Should patients/patient representatives insist upon the use of a friend or family member to provide them with interpreting service, LBM personnel shall additionally retain a healthcare interpreter to participate in the exchange to ensure that it represents an accurate portrayal of the information to hospital staff and patients. Necessary emergency care should not be withheld pending the arrival of interpreter services. Contact numbers and access codes for the direct contact of contracted interpreter services shall be available to Emergency Room staff. Qualified healthcare interpreters at LBM include:
    a. LBM Healthcare Interpreters (see definition)
    b. LBM Assessed Bilingual Employees (see definition)
    c. Outsourced interpreter services meet the qualifications of healthcare interpreting determined by LBM through contractual agreement and agency standards.

  4. Acceptable methods for the provision of interpreter services include, but are not limited to the following:
    a. In-person interpreting
    b. Telephone-based interpreting
    c. Videoconferencing interpreting

  5. Mechanisms for the provision of interpreter services and language access support at LBM must be available to clinical areas of hospital inpatient and outpatient services during their hours of operation.

  6. Considerations for determining the appropriate model for the delivery of interpreter services will include the critical nature of the clinical interaction, availability of healthcare interpreters and of the technology to allow for telephonic or videoconference interpreters. Additional considerations such as the shortest wait times for patients and clinicians and the most cost-effective use of contracted agencies also will be considered.

  7. It is the policy of LBM to translate and make available Vital Documents in Threshold Languages. Vital Documents that are not produced in a written translation shall be verbally translated to the patient or surrogate decision-maker. The provision of sight translation of all Vital Documents to patients shall be documented.

1 California Standards for Healthcare Interpreters: Ethical Principles, Protocols, and Guidance on Roles and Intervention. California Healthcare Interpreting Association (2002): 76. (available at http://www.calendow.org/reference/publications/pdf/cultural/ca_standards_healthcare_interpreters.pdf).

2 CAL. HEALTH & SAFETY CODE §1367.04(b)(1)(B)(i)-(vi) (available at http://www.leginfo.ca.gov/cgi- bin/calawquery?codesection=hsc).

3 According to the Title VI Office of Civil Rights Guidance, the definition of Vital Documents “may depend upon the importance of the program, information, encounter, or service involved, and the consequence to the LEP person if the information in question is not provided accurately or in a timely manner.” (available at http://www.usdoj.gov/crt/cor/lep/hhsrevisedlepguidance.html).

California Standards for Healthcare Interpreters: Ethical Principles, Protocols, and Guidance on Roles and Intervention. California Healthcare Interpreting Association (2002): 69. (available at http://www.calendow.org/reference/publications/pdf/cultural/ca_standards_healthcare_interpreters.pdf).

PROCEDURE:
  1. Procedure for the Determination of LEP and Hearing Impaired Status:
    a. The first access point in which a patient acquires services at LBM (admissions, registration, etc.) shall document the patient’s preferred language and interpreter need in the EPIC Patient Demographic Profile.
    b. The patient or surrogate decision-maker shall be asked for their preferred verbal and written language in the Patient Learning Assessment.
    c. Areas of first patient contact shall be equipped with Language Identification Cards to assist patients in identifying the patient preferred language if communication barriers prevent hospital staff from effectively determining the language of the patient/surrogate decision-maker. The Language Identification Card will visually show all languages hospital staff can reasonably project they will encounter. Patients will be offered the card to allow them to point to their language on the card to allow hospital staff to request interpreter services in the appropriate language. The Interpreter Service Department should be called if the patient is unable to use the Language Identification Card, and hospital staff cannot determine the appropriate language to request. Interpreter Service will contact or direct the requestor to contact the contracted telephone interpreter service to determine language. If interpreter services is unavailable, Central Staffing should be contacted to provide a dual-handset phone should a telephone interpreting phone not be available in the unit where needed.

  2. Procedure to Inform Patients of their Right to Have Interpreter Services: LBM shall post notices that advise patients and their families of the availability of interpreters, the procedure for obtaining an interpreter and the telephone numbers where complaints may be filed.

  3. Procedure for the Tracking of LEP and Hearing Impaired Patients in Hospital Data Sets: The language needs of patients and surrogate decision-makers will be recorded and tracked. This critical information will be captured and recorded in EPIC. It shall be stored in the area containing the Patient Demographic Profile and Patient Learning Assessment.

  4. Procedure for the Acquisition of Interpreter Services: The Interpreter Service Department is available 24/7. Hospital personnel seeking interpreter services for patients or patient representatives requiring language assistance shall utilize the following procedures:
    a. To access or schedule Spanish or Cambodian (Khmer) Healthcare Interpreters:
       i. Call extension 31113 or page 17825.
       ii. Provide Patient Name, Location, Nature of Communication, Time and Estimated Duration of Assignment, and Providers Name and Extension.
    b. To access or schedule an interpreter for languages other than Spanish or Cambodian (i.e. American Sign Language (ASL), Vietnamese, Korean, etc.)
       i. Call extension 31113
       ii. Provide Patient Name, Location, Nature of Communication, Time and Estimated Duration of Assignment, Providers Name and Extension, and the Department Cost Center Number where services will be charged.
       iii. Complete an Interpreter Request Form (Visit Department Page > Interpreter Services) and fax to extension 33946
    c. If no healthcare interpreter is immediately available, use telephone interpreting services available throughout the hospital. In situations where a dual-handset telephone cannot be used, a regular hospital phone can be used to connect to the telephone interpreting service provider.
    d. New employees of LBM will be trained in the procedure for the acquisition of interpreter services during their New Hire House Orientation to LBM. Training on this procedure for current LBM staff will be incorporated into other reorientation trainings for employees such as customer service trainings, skills day, annual patient safety module, and updates on new regulatory requirements.

  5. Procedure for the Provision of Written Translations:
    a. Departments originating documents in English which require written translation shall submit them in English in their final and approved form to the manager of Customer and Interpreter Service. To request written translation:
       i. Complete a Translation Request Form (Visit Department Page > Interpreter Services) and e-mail to Interpreter Services Manager
       ii. Provide your Name and Extension and the Department Cost Center Number where services will be charged (if non-Spanish or urgent)
       iii. Submit documents to be translated via e-mail in Microsoft Word or Publisher Format
    b. Quality assurance methodology for the development of written translations of the Vital Documents of LBM shall be as follows:
       i. The originating document will be translated into the second language.
       ii. The draft written translation will be reviewed and corrected by a second translator.
       iii. In the case of med-legal documents covering matters such as informed consent or culturally sensitive issues, the translated material will be reviewed by a third translator to ensure accuracy and cultural sensitivity.
    c. No written translations from web sites or other institutions will be used by LBM unless the above standards for the translation process and copyright considerations have been met.

  6. Procedure for Language Accessible Hospital Signage
    a. Hospital signage at LBM shall be designed to ensure access to LEP populations most frequently using LBM facilities. All signage required by state and federal statutes, regulations and licensing requirements will be translated into all languages other than English when a proportion of 5% of the patient population of LBM has that language as their primary language. 5 Additional languages for the translation of signage shall be added at the discretion of hospital management.
    b. These requirements for posting language accessible signage shall be implemented during the creation of any new signage of LBM.

  7. Procedure for Hospital Equipment Requirements to Assure Language Access
    a. Clinical areas shall be equipped with devices necessary for the routine delivery of remote interpreter services through telephone or videoconferencing. Service areas requiring devices for the delivery of remote interpreter services include (but are not limited to) the following:
       i. Stations of patient registration, financial counseling, and admission
       ii. Designated exam rooms and in-patient beds
       iii. Nursing stations
       iv. TTY (teletypewriter) available on public telephones
    b. Devices to allow effective access to remote interpreter services may include the following:
       i. Dual handset and/or headset telephones
       ii. Speakerphones
       iii. Telephones equipped with three-way call capability for telephone-based services
       iv. Videoconferencing stations
    c. Communication Devices/Adaptive Equipment (For hearing impaired patients) Call the hospital operator at extension “0” and request a T.D.D.
    d. These standards shall be applied to new outfitting activities involving hospital telecommunication services, including renovations and new facilities construction. Equipment purchases in medical settings that most greatly affect quality of care, patient safety, and improved patient outcomes (for example the emergency room and pharmacy) will be designated for immediate remediation.

5 Such requirements include the Emergency Medical Treatment and Active Labor Act, Title VI of the 1964 Civil Rights Act and the Kopp Act [Cal. Health & Safety Code §1259].

DOCUMENTATION:

Procedure for the Inclusion of Patient Preferred Language and Documentation of the Provision of Interpreter Services in Patient Medical Records:

  1. Each medical record shall show the preferred language spoken and preferred language for medical communication by the patient/surrogate decision-maker. In addition, any cognitive or perceptual alterations such as hearing and/or visual impairments will be documented.

  2. The patient need for interpreter services shall be included in the following areas of documentation:
    a. Patient Demographic Profile
    b. Patient Learning Assessment

  3. The Interpreter Service Department will document every interpreter request and encounter in the Interpreter Log.

REFERENCES:

Title VI of the 1964 U.S. Civil Rights Act, 42 U.S.C. § 2000d.

Office of Civil Rights, U.S. Department of Health and Human Services, Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons, 68 Fed. Reg. 47311 (Aug. 8, 2003).

California Government Code §§ 11135 and 7290 et seq. California Health and Safety Code § 1259

The Joint Commission Comprehensive Accreditation Manual for Hospitals

Office of Minority Health, U.S. Department of Health and Human Services, National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care, 65 Fed. Reg. 80865 (Dec. 22, 2000). 

Orange Coast Memorial

Interpreter Services/Services to the Visually Impaired

SCOPE:

To define the resources available at the hospital to provide interpreter services, and the services available to visually impaired patients.

POLICY:

It is the policy of this hospital to ensure adequate and speedy communication between patients and staff in order to provide quality health care in a considerate and caring manner. The hospital maintains compliance with state and federal legislation and accrediting agency guidelines pertaining to interpreter services and has established a mechanism to provide interpreter services to all patients as needed. The staff is notified of the policies and procedures regarding the provision of interpreter services, including procedures to obtain interpreter services when needed and the commitment to provide interpreters to all patients identified or requested. The hospital also is sensitive to the needs of blind patients and provides resources for them to enhance their hospital experience and discharge plans.

DEFINITIONS:
  1. Communication Barrier: An impairment in hearing, sensory, or speaking skills.

  2. Hearing Impairment: Any degree of diminished or defective ability to apprehend sound; this includes total deafness.

  3. Interpreter: A person fluent in English and in the necessary second language who can accurately speak, read, and readily interpret the second language. An interpreter has the ability to translate the names of body parts and to describe symptoms and injuries in English and the necessary second language.

  4. Language Barrier: A barrier experienced by individuals who are limited English-speaking or non-English-speaking who comprise at least five percent (5%) of the population of the geographical area served by the hospital or of the actual patient population.

  5. Sign Language: A language used by the deaf. A formal language employing a system of hand gestures for communication especially among deaf people.

  6. Oral Interpreter: Silently mouth interprets speech for non-signing deaf or hard of hearing.

GUIDELINES:
  1. Upon admission or registration, the primary language (if other than English) of each patient is identified and recorded on the face sheet of the patient’s chart.

  2. Admitting Department is responsible for capturing this information for each patient upon admission/registration or in the Emergency Department.

  3. Hearing Impaired:
    a. Certified sign language interpreters and oral interpreters are available through an interpreter for the Disabled COMMEND Program twenty-four (24) hours a day.
    b. Contact the nurse manager, Administrative House Officer, or Social Work Services Department for the telephone number to arrange for interpreter services.
    c. Service requires the following information:
       1. Name and number of person requesting service
       2. Date and time service is needed (if not an emergency)
       3. Client’s name
       4. Nature of assignment
       5. Kind of sign language needed
       6. Person to whom to report

  4. Language Barriers: Language Line Services:
    a.Interpreters are available twenty-four (24) hours a day, seven (7) days a week. A trained, professional interpreter is available within minutes. The interpreter is trained in medical interpretation.
    b. To access this service (888.338.5533) the following information is needed:
       1. Account code: PT267
       2. Your name
       3. Phone number you are calling from
       4. Department you are calling from
       5. Language needed
    c. Dual interpretation phones are found on each unit. One phone is for the healthcare provider and one for patient/family.

  5. Visually Impaired Patients:
    a. The Braille Society’s Field Instructor Program is available to provide inservices and training to staff regarding the needs of visually impaired patients.
    b. As requested by a patient, a referral may be made to the Braille Society to train the patient in activities of daily living skills, independent living skills, and other Braille Society programs.
    c. The Social Work Department makes referrals upon request.

Saddleback Memorial

Interpreter Services For Non-English Speaking and Hearing Impaired Patients and Families

PURPOSE:

To provide quality patient care for limited English proficiency (LEP) and hearing impaired patients through effective communication and collaboration.

DEFINITION OF TERMS:

Limited English Proficiency (abbreviated at LEP):
Term is defined by Title VI of the Civil Rights Act of 1964 as applying to those patients whose native language is other than English and who “cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers.”

POLICY:

Policy on the Provision of Medical Services to Patients/Surrogate Decision-Makers Needing Language Assistance:

  1. Patients/surrogate decision-makers who are LEP or hearing impaired, shall have services provided to them in their primary language or have interpreter services provided to them during the delivery of all significant healthcare services. Interpreter services shall be available and at no cost to patients.

  2. Effective communication is important in every area of hospital communication, but prioritizes the most careful attention to effective communication in the provision of medical, nursing, and ancillary services, where patient safety, medical error, and ability to understand treatment options are affected. Types of encounters and procedures which are performed by providers who do not speak the primary language spoken by the patient/surrogate decision- maker, and which require the use of healthcare interpreter services, include, but are not limited to:
    a. Providing clinical and emergency medical services,
    b. Obtaining medical histories,
    c. Explaining any diagnosis and plan for medical treatment,
    d. Discussing any mental health issues or concerns,
    e. Explaining any change in regime or condition,
    f. Explaining any medical procedure, tests, or surgical interventions,
    g. Explaining patient rights and responsibilities,
    h. Explaining the use of restraints or seclusion,
    i. Obtaining informed consent,
    j. Providing medical instructions and explanation of potential side effects,
    k. Explaining discharge plans,
    l. Discussing issues at patient and family care conferences and/or health education sessions,
    m. Discussing Advance Directives,
    n. Discussing end of life decisions, and,
    o. Obtaining financial and insurance information.

  3. The policy of Saddleback Memorial is to provide patients and surrogates decision-makers requiring language assistance with medical care in their primary language spoken by using the interpreter service.
    a. LEP and hearing impaired patients/surrogate decision-makers shall be advised of their right to have interpreter services.
    b. Family members are not to be asked to interpret as this violates HIPAA privacy regulations.
       1. Should patients/patient representatives insist upon the use of a friend or family member them with interpreting service, the staff member shall utilize the language interpretation service and telephone to ensure that it represents an accurate portrayal of the information to hospital staff and patients.
       2. Emergency care should not be withheld pending obtaining the language telephone.

OUTSIDE RESOURCES
  1. Dayle Mcintosh Center (Sign Language)
    a. Saddleback Memorial is contracted with the Dayle McIntosh Center. The Dayle McIntosh Center will provide the following services when necessary:
       1. Provide personnel trained in sign language
       2. Provide 24-hour service with a 30-45 minute response time.
    b. Phone number Mondays through Fridays from 0830 to 1700 is: 714-621-3300
       1. Number to call on off hours is: 800-422-7444 LANGUAGE INTERPRETATION SERVICE AND TELEPHONE
       2. The AT&T Language Interpretation service provides instant access to interpreters who speak more than 140 languages. The Service maintains a 24-hour communications center staffed with highly trained interpreters and linguists
    c. PROCEDURE FOR USE OF THE SERVICE AND THE TELEPHONE
       1. To use the service, take the language line phone that has been supplied to your unit to the patient’s bedside.
       2. Plug the phone to the bedside phone jack or any analog phone lines (fax or printer phone jacks).
       3. The phone has two handsets. Pick up the handset with the green sticker and wait for dial tone. Press the red button on the base.
       4. Follow the prompt to “press 1 for Spanish” and “press 2 for other languages”.
       5. Follow prompt to “press the client ID button” and give the Saddleback Memorial client ID number which is 201166. An operator will come on the line and identify himself/herself by announcing her Operator number. He/she will then ask you for your individual ID number. Give your employee ID number.
       6. Document in Epic “A T & T Interpreter #_____”.
       7. Hand the other handset to the patient. Begin communicating with the patient with the assistance of the interpreter.
       8. To reach a staff interpreter for life or death emergency situations ONLY, dial 1-800-523-1786. Once you are directly connected into the central communication facility, give the operator this access code: PIN #201166. This PIN is specifically for Saddleback Memorial use only.
    d. PROCEDURE FOR THE USE OF CLINICAL MOBILE TELEPHONE
       1. Phone number Mondays through Fridays from 0830 to 1700 is: 714-621-3300
       2. Phone number to call after hours is: 1-800-422-7444
       3. Follow the prompt to “press 1 for Spanish” and “press 2 for other languages”.
       4. Follow prompt to “press the client ID button” and give the Saddleback Memorial client ID number which is 201166. An operator will come on the line and identify himself/herself by announcing her Operator number. He/she will then ask you for your individual ID number. Give your employee ID number.
       5. On your document in Epic, enter the “At & T Interpreter #_____”.

  2. TDD TELEPHONE (HEARING IMPAIRED)
    a. The TDD telephone is located in the Emergency Services Department in the treatment area.
    b. The telephone number is 1-800-855-2881

REFERENCES:
California Health and Safety Code €1259
California Government Code € 11135 and 7290 et seq
The Joint Commission Standards 2012: PC.02.01.21; RI.01.01.01;RI.01.01.03