Download Slide 1

Preparing for the JCIA
Consultation Survey
1
What will be presented
 AUBMC Accreditation timeline
 How JCIA standards are spelled out
 How to get ready for the consultation
survey
 What you need to know
 International Patient Safety Goals
2
AUBMC Accreditation Timeline
Apr 16, 2007
JCIA Consultation Survey
Today
Feb 2007
Mar 2007
Apr 2007
May 2007
2007
Actual JCIA
Accreditation Survey period starts
Jun 2007
Jul 2007
Aug 2007
Jan 2007
Sep 2007
Oct 2007
 JCIA Consultation Survey April
16 – 20th 2007
 Depending on the survey
findings, and after a 6 months
notification period, the actual
JCIA survey can be conducted
 MOPH Accreditation visit is due
in May 2007
3
How JCIA standards are spelled
out
Statement of
the standard
Intent
Measurable
Elements
PFR.9.4 Informed consent is obtained before surgery, anesthesia, use of blood and
blood products, and other high-risk treatments and
procedures.
Intent of PFR.9.4
When the planned care includes surgical or invasive procedures, anesthesia,
use of blood and blood products, or other high-risk treatments or procedures,
a separate consent is obtained. This consent process provides the information
identified in PFR.9.1 and documents the identity of the individual providing
the information.
Measurable Elements of PFR.9.4
1. Consent is obtained before surgical or invasive procedures.
2. Consent is obtained before anesthesia.
3. Consent is obtained before the use of blood and blood products.
4. Consent is obtained before other high-risk procedures and treatments.
5. The identity of the individual providing the information to the patient and
family is noted in the patient’s record.
4
How to get ready for the
consultation survey
 AUBMC Mission Statement
 AUBMC policies & procedures manual
 Departmental policies & procedures
manual
 AUBMC Safety/Emergency Plans
●
●
●
●
●
●
●
●
Safety plan
Security plan
Hazardous material & waste
management plan
Emergency response plan
Fire safety plan
Medication equipment plan
Utility systems plan
Infection control manual
5
The JCIA
Standards
What you need
to know
6
What you need to know
Access to Care and Continuity of Care
Care planning upon admission:
• Proposed plan of care :Diagnostic tests and or
proceedures planned
• Expected results of care
• Financial cost or its expectations
Reference: Admission of Patients (ACC-MUL-001)
7
What you need to know
Access to Care and Continuity of Care (cont’d)
• Admission/transfer/discharge to or from
intensive/specialized care units is determined
by established criteria..
Reference: Critical Care unit manual, Transfer of
Patients (ACC-MUL-003)
• Attending responsible for patient care during
all phases.
Reference: Transfer of Patients (ACC-MUL-003),
Medical Staff Bylaws
8
What you need to know
Access to Care and Continuity of Care (cont’d)
• Sharing of patient information among medical,
nursing and other care providers during each
staffing shift, between shifts and during
transfers between units.
• Availability of patient’s medical record
throughout.
• Coordination of care between diagnostic and
treatment services.
Reference: Multidisciplinary Notes, Transfer of
Patients (ACC-MUL-003), Medical Record
Content & Documentation (MOI-MUL-003)
9
What you need to know
Access to Care and Continuity of Care (cont’d)
• Discharge instructions, discharge summary.
Patients records contain a copy of the
Discharge Summary.
Reference: Patient Discharge Instructions (ACCMUL-004), Medical Records Manual
• Continuity of care after transfer, sharing of
information on patient condition, patient
monitoring during transfer, documentation of
transfer.
Reference: Transfer of Patients (ACC-MUL-003)
10
What you need to know
Patient and Family Rights
• Patient & family are informed of Patient Bill of
Rights and participation in care process.
Reference: Patient handbook
• Confidentiality of patient information
Reference: Confidentiality, Security, Privacy &
Release of Patient Information (MOI-MUL-002)
• Complaints & complements: Patients are
informed about the process.
Reference: Complaints & Complements
Guidelines (GLD-ADM-003); Patients Handbook
11
What you need to know
Patient and Family Rights (cont’d)
Informed consent:
• Obtain informed consent for special procedures (list
identified).
• Inform patient/family/guardian, in a language/format
that is understood, about proposed treatment for care
decisions.
• Document signature of patient/family/guardian on
informed consent and specify name of guardian.
Reference: Patient Consent (PFR-MUL-001)
Mission Statement:
Reference: AUBMC website & posted within AUBMC;
Patients Handbook
12
What you need to know
Assessment of Patients
• Medical needs are identified from the initial
assessment.
• Scope and content of assessment are defined and
within the law.
• Individualized assessment for special populations.
• Pain assessment is uniform.
• Completion of assessment within specified time
frame.
• Assessment findings are documented & readily
available.
• Reassessment is done at appropriate intervals.
Reference: Multidisciplinary Assessment and
Reassessment of Patients (AOP-CLN-001)
13
What you need to know
Assessment of Patients (cont’d)
• Results are available in a timely manner .
• Critical test results: reporting and
documentation.
Reference: Critical Test Results (COP-MUL018)
14
What you need to know
Care of Patients
• Patient care plan: Patient care is planned,
documented & revised with change of condition.
Reference: Care Delivery for all Patients (COP-MUL008), Multidisciplinary Assessment and
Reassessment of Patients (AOP-CLN-001), Medical
Staff Bylaws, progress notes in patient medical
record
• Physicians Orders: Those permitted to write patient
orders write the orders in the patient’s record in a
uniform location.
Reference: Physicians orders (COP-MUL-007),
Medical Staff Bylaws
15
What you need to know
Care of Patients (cont’d)
Resuscitation services:
• Code Team (Adult, Pediatric & Adolescents,
Neonates) Services.
• Crash Carts on all in-patient units.
Reference: Adult Code Team (COP-MUL-013),
Pediatric & Adolescent Code Team (COP-MUL-021),
Neonatal Code Team (policy under development)
(COP-MUL-022), Medical Staff Bylaws
• Blood and blood products: Process to guide the
handling, use and administration.
Reference: Use of Blood/Blood Products (COP-MUL001)
16
What you need to know
Care of Patients (cont’d)
• High-risk patients: Care of patients on life
support or who are comatose; care of patients
with a communicable disease and immunesuppressed patients; care of patients on
dialysis.
Reference: Care of High-Risk Patients (COP-MUL017), Nursing Administration Manual (NSGCOP-059), BMT Manual, Kidney Dialysis Unit
Manual
• Physical restraint:Process on the use of restraint
and the care of patients in restraint.
Reference: Physical Restraint (COP-MUL-015)
17
What you need to know
Care of Patients (cont’d)
• Care of vulnerable patients: Process to guide
the care of vulnerable elderly patients and
children.
Reference: Care of Vulnerable Patients (COPMUL-016)
• Moderate sedation: Process to guide the care
of patients undergoing moderate and deep
sedation.
Reference: Moderate (Conscious) Sedation
(COP-MUL-002) under development
18
What you need to know
Care of Patients (cont’d)
Medication Use: control of medication samples, no
patient self-administration of medications,
medication orders written by certified physicians.
Reference: Physician's Orders (COP-MUL-011),
Medication Samples (COP-MUL-012)
Medication errors / ADE:
• Adverse medication effects are noted in the
patient’s record.
• Medication errors are reported through a process.
Reference: Adverse Drug Event Reporting (COP-MUL004)
19
What you need to know
Care of Patients (cont’d)
 End of life care: Assessment and reassessment of
dying patient include symptoms, the dying
patient’s and family’s psychological status and
spiritual needs.
Reference: End of Life Care (COP-MUL-014)
Pain assessment & management:
• Pain assessment is a requirement.
• Effective pain management.
• Patient education on pain and pain free hospital
stay.
Reference: Pain Assessment and Reassessment (COPMUL-005), Pain Management (COP-MUL-007)
20
What you need to know
Patient and Family Education
• Starts with understanding financial implications
of care choices, signing informed consent,
and participating in care process.
• Educates patients on relevant topics.
• Education methods appropraite to patient’s
understanding, consider the patient’s and
family’s values and preferences.
Reference: Patient and Family Education (PFEMUL-001), Patient Discharge Instructions (ACCMUL-004), Patient Consent (PFR-MUL-001),
Patient Rights & Responsibilities (PFR-MUL-002)
21
What you need to know
Quality Improvement and Patient Safety
PDCA Model, indicators, medical staff participation
Reference: PI Plan (QPS-MUL-002).
Incident reporting, monitoring of medical errors.
Reference: Patient-Related Risk Management Plan (QPSMUL-001)
Prevention and Control of Infection
The hospital wide PCI Manual is still under development by
the ICP.
Governance Leadership and Direction
Departmental Policy and Procedure Manual, know the
content.
22
What you need to know
Facility Management and Safety (manual under
development )
• Fire safety: RACE, PASS, 5555
• No Smoking policy in AUBMC
• Disaster plan: 9999, participation in drills
• Hazardous Materials & Wastes: follow segregation
guidelines.
• Security: safegaurd children and vulnerable
patients.
• Equipment management: training on new
equipment, ensure functionality before patient use.
23
What you need to know
Staff Qualification and Education
• Medical Staff credentials:
Reference: Re-appointment of Medical Staff
& Renewal of Clinical Privileges (SQE-MST001)
• Continuing education: In-service training
for staff, annual training for Fire Safety,
BLS/ACLS/PALS training every 2 years.
Reference: Continuing Medical Education
(SQE-MST-003)
24
What you need to know
Management of Information
• Identification data, date, time and author
of the entry in medical record.
• Error-prone abbreviations.
• Protection of records.
• Access to information in patient medical
record upon each care episode.
Reference: Medical Record Content &
Documentation (MOI-MUL-003)
25
2007 International Patient Safety
Goals
26
2007 International Patient Safety Goals
Poster
27
28
Goal #1: Identify Patients Correctly
Patient room number should not be
used for patient identification.
Patient Identification Policy
COP-MUL-009
29
30
Goal #2: Improve Effective
Communication
 Verbal orders have to be “read back”
by the receiver to check for
accuracy.
Other communication methods used in
AUBMC include:
 Inter-shift report by nursing staff.
 On-service/off-service notes in the
Multidisciplinary Notes.
 Hand over report between house staff.
 Multidisciplinary morning rounds.
31
32
Goal #3: Improve the Safety of
High-Alert Medications
Nursing & Pharmacy
Committee is
working on the list of
high alert
medications.
33
34
Goal #4: Eliminate Wrong-Site, WrongPatient, Wrong-Procedure Surgery
Pre-operative/Pre-procedure Verification
Form:
 First Verification is performed by the
nurse before pre-medication.
 Second Verification is performed by the
nurse before the procedure.
 Third Verification, “TIME OUT”, is
performed just before starting the
procedure.
 “TIME OUT”: the nurse initiates the
process, the surgeon and anesthetist
verify the correct patient name,
procedure and site.
35
36
Goal #5: Reduce the Risk of Health
Care-Associated Infections
All AUBMC Personnel shall use proper hand
hygiene before & after:
● Patient contact
● Applying gloves for any patient
related procedure such as: centralvenous catheters (CVC), inserting
urinary catheters, peripheral vascular
catheters, or other invasive devices
that do not require surgery
● Eating, drinking, preparing or
handling food
37
38
Goal #6: Reduce the Risk of Patient
Harm Resulting From Falls
 Fall Risk Assessment Tool: initiated
upon admission, then weekly and
as condition evolves, for adults.
 According to the findings, the
patient is categorized as “at Risk” or
“No Risk”.
 If patient is at risk of fall, the patient
is put on fall risk precaution.
 In pediatric population, fall
precaution is done daily.
39
40