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Joint Commission
Readiness
Riley Lunch and Learn
Michele Saysana, MD
August 18, 2010
The Joint Commission (TJC)
• Formerly know as JACHO
• Accredits health care organizations based
on quality and safety standards
• Findings are made public
How do they evaluate us?
• 12-14 surveyors, 1 week, every 3 years
• IU, Riley, and Methodist
• Tracer Methodology
– Follow a patient through the system
– Nursing, Physicians, Environment of Care,
Pharmacy, Human Resources
Quick Tips
• Be polite
• Do NOT run from a surveyor
• Use your resources
– Little red book
– Emergency Reference Info tag
– 2010 National Patient Safety Goals
Orders
• ALL orders need to have
– Date
– Time
– Legible name
– Dictation number
• PRN orders must have a indication
– Pain, fever, etc.
Verbal Orders
• All verbal orders MUST be signed within
48 hours
• We are at ~80% compliance
• Sign in Cerner on Orders tab
Fast Facts
What do you do if there is a fire in the
hallway right now?
Rescue Activate Contain Evacuate
Pull the pin Aim Squeeze Sweep
Culture of Safety Survey
• Strengths
– Teamwork
– Leadership expectations and actions promote
safety
• Areas for improvement
– Handoffs and transitions
– Feedback and communication about error
Medications
• All syringes must be labeled
– Drug
– Concentration
– Amount in the syringe
• Exception – if you are giving the
medication as soon as you draw it up
Culture of Safety Survey
• Annual, nationwide survey
• Identifies hospital employees and medical
staff perception of safety
• Riley’s overall grade 81%
– Best of IU/RI/MH
Fast Facts
Who do you ask to be paged if you need
security called? (i.e. the codename)
Dr. Armstrong
OPPE
• Ongoing Professional Practice Evaluation
• Monitoring of Medical Staff performance in
relation to measures identified by each
service
• Coordinated by Clarian Medical Staff
Office
FPPE
Focused Professional Practice Evaluation
– New medical staff members
– Existing members granted new privileges
– If identified trends in OPPE
•
•
Review based on service/specialty
Coordinated by Clarian Medical Staff
Office
Fast Facts
Where should your ID badge hang?
Above the waist
Performance Improvement
PI = QI = CQI = Quality
Improvement
TJC uses PI to refer to performance
improvement
So what are our Riley PI projects?
• Hand Hygiene
• Handoffs/Transitions
– Nurse bedside report
– Resident Handoffs
• CaBSI – Catheter associated blood stream
infections
So what are our Riley PI projects?
• Asthma Action Plans
– 100% compliance at Riley
• ID Bands – improving the rate of proper
patient identification
– Decreased the error rate from 18% to 5%
Fast Facts
What are 3 ways to promote patient
confidentiality?
Do NOT discuss patients in public
No names on white boards
Log off Cerner, Careweb, Synapse when
not in use
Infection Control
• Wash hands when entering and exiting
rooms
• Follow directions on isolation signs
• Wear PPE when exposed to bodily fluids
• Clean stethoscope between patients
Consent
All procedural consents MUST include:
– Procedure
– Name of Treating Practitioner
– Patient’s name either printed or labeled on the
consent
– Patient or patient’s representative sign, date,
& time consent
– Treating practitioner’s signature and date
Universal Protocol
• Procedural site labeling – including laterality
must be performed.
• Procedural Time Outs
– Stop activity
– Focus on the TIME OUT
– OR, bedside, treatment room, ED
• Completed Consent MUST be on chart
Fast Facts
Name the 3 Disaster Codes
Code Blue – medical emergency
Code Red – fire
Code Adam – infant/child abduction
Post-Anesthesia Evaluation
• After the patient has the opportunity to
recover from anesthesia
• Within 48 hours of the procedure ending
• MUST be documented in the medical
record
Operative Note
• Immediate post-procedure note MUST be documented
following all procedures and include:
– Names of the primary surgeon and assistants
– Preoperative and postoperative diagnosis
– Technical details of procedure
– EBL
– Specimens removed
– Description of findings
– Condition of the patient at the end of the procedure
• Dictated operative notes MUST be completed within 48
hours of the procedure
Restraint Orders
The Joint Commission and CMS have very specific
guidelines for restraint use.
Restraint Orders
• Cannot have a start and stop time per day.
• Cannot have a “trial off” period.
• Need new order each and every time a restraint is
restarted.
• Continual use of restraints needs to have a daily
restraint order.
Fast Facts – Last One!
Name 2 National Patient Safety Goals
Fast Facts – Last One!
1.
2.
3.
4.
Improve accuracy of patient identification
Improve communication among caregivers
Improve safety of medication use
Reduce risk of healthcare associated
infections
5. Accurate medication reconciliation
6. The organization identifies safety risks
7. Universal Protocol to prevent wrong
site/wrong procedure/wrong patient
surgery