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Issue 1 Trinitas Hospital Education Department JCAHO 2005 Series JCAHO Jewels 2005 National Patient Safety Goals ♦ Improve the accuracy of patient identification. ♦ Improve the effectiveness of communication among caregivers. ♦ Improve the safety of using medications. JCAHO: Shared Visions-New Pathways • • • • ♦ Improve the safety of using infusion pumps. ♦ Reduce the risk of health care acquired infections. ♦ Accurately and completely reconcile medications across the continuum of care. ♦ Reduce the risk of patient harm resulting from falls. ♦ Improve the effectiveness of clinical alarms. • Universal Protocol is implemented. • JCAHO stands for the Joint Commission on Accreditation of Healthcare Organizations. This organization surveys healthcare organizations to assess that high quality care is delivered safely and efficiently. The new survey process, Shared Visions-New Pathways, was developed to ensure that healthcare organizations provide a continuum of safe, high-quality care. Changes to the survey process include: • New survey structure: Tracer Methodology • Revised accreditation decision process • Unannounced surveys beginning January 2006 Patient tracking using the Tracer Methodology approach: • Surveyors will focus on several patients and use their charts as a guide to his or her hospital stay, including all of the services that he or she received while at Trinitas. • For example, the surveyor may choose a patient on 6 South who was admitted through the ED, went to Radiology, OR and PACU and then recovered on 6S. • Staff members on these units must be able to answer questions about the care the patient received while in their unit, communication between departments, patient safety issues, etc. Every Trinitas employee plays a key role in helping our hospital to meet JCAHO standards. Together, we share a commitment to provide quality health care to all members of the community. Tracer methodology is the process the surveyors will use during an on-site survey. Tracer activity will: ♦ Start in the setting/unit where a patient is currently located ♦ Follow the course of care and services provided to the patient ♦ Assess relationships among disciplines Tracer methodology is a “connect the dot” approach that addresses the interdisciplinary relationships that exist during the patient’s hospital stay . . . And translates standards compliance into quality patient care.