Download JCAHO Jewels JCAHO Overview

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.