Download JCAHO Leadership Council - Healthcare Professionals

JCAHO Update
John D. Crossley, RN, PhD
Why do Residents care about
JCAHO
It is required that an academic medical center with a residency training
program be accredited.

The Accreditation Council on Graduate Medical Education (ACGME)
Institutional Requirements state: 'Institutions sponsoring participating
GME programs should be accredited by the JCAHO, if such institutions
are eligible.

If an institution is eligible for JCAHO accreditation and chooses not to
undergo such accreditation, then the institution should be reviewed by
and meet the standards of another recognized body with reasonably
equivalent standards. If the institution is not accredited, it must provide
a satisfactory explanation of why accreditation has not been either
granted or sought.'

ACGME notes that certain specialty training programs , like general
surgery should be conducted in institutions accredited by JCAHO.
http://www.aha.org/aha/key_issues/patient_safety/accreditation/
Why do residents care about
JCAHO
A hospital or health system that does not have deemed
status is able to participate in Federal health care programs
such as Medicare – which funds GME- but:
If a hospital or health system chooses not to be accredited
by either the JCAHO or the American Osteopathic
Association, the organization will be subject to periodic
surveys by personnel of the respective state agency that
licenses hospitals and other health care facilities (or its
equivalent). The results of such surveys will serve to
determine whether a hospital or health care system is
eligible to participate in such Federal programs as Medicare.
http://www.aha.org/aha/key_issues/patient_safety/accreditation/
The Old JCAHO
 Scheduled months in advance
 Primarily a retrospective review
 Small teams of part-time surveyors with
limited training
 Unstructured care area visits
 Focus on prior survey reports
 Tailored primarily to national highvolume diagnoses
The New JCAHO
 No scheduled surveys
 Minimal retrospective review
 Larger teams of full-time surveyors with
extensive training
 Tracer methodology
 Global priority focus areas
 Tailored to current inpatient census
Previous Survey Process
 Structured, based on physical patient
care areas
 Uniform across all organizations
surveyed
 Unit/clinic visits tightly scheduled and
controlled
 Primarily managerial staff participation
in survey
 Main focus on policies and procedures
New Survey Process
Tracer Methodology
 Process-driven, directed by priority
focus areas
 Customized to the individual health care
organization
 Surveys follow provision of services
across physical and programmatic
boundaries
 Multi-level staff participation
 Main focus on actual care delivery
Priority Focus Areas
 Each standard relates to one or more
priority focus area
 “Processes, systems, or structures in a
health care organization that
significantly impact the quality and
safety of care.”
2005 CAMH
 Serve to integrate chapter elements of
the accreditation standards
JCAHO hospital safety goals
Goal: Improve the accuracy of patient
identification.
 Use at least two patient identifiers
(neither to be the patient's room
number) whenever administering
medications or blood products; taking
blood samples and other specimens
for clinical testing, or providing any
other treatments or procedures.
JCAHO hospital safety goals
Goal: Improve the effectiveness of communication among
caregivers.
 For verbal or telephone orders or for telephonic reporting of
critical test results, verify the complete order or test result by
having the person receiving the order or test result "readback" the complete order or test result.
 Standardize a list of abbreviations, acronyms and symbols that
are not to be used throughout the organization.
 Measure, assess and, if appropriate, take action to improve
the timeliness of reporting, and the timeliness of receipt by
the responsible licensed caregiver, of critical test results and
values
Standardized list of abbreviations
1.
2.
3.
4.
Q.D.
Q.O.D.
U.
IU
Write
Write
Write
Write
“daily”
“every other day”
unit
international unit
Standardized list of abbreviations
5. Trailing zero (1.0 mg)
Never write a zero by itself after a decimal point
(1 mg)
6. Lack of leading zero (.1mg)
Always use a zero before a decimal point (0.1 mg)
Standardized list of abbreviations
7. MS
8. MS04
9. MgSO4
10. Ug
11. Cc
12.T.I.W.
Write morphine sulfate or
magnesium sulfate
Write morphine sulfate
Write magnesium sulfate
Write mcg or micrograms
Write ml or milliliter
Write 3 times weekly or
three times weekly
JCAHO Hospital Safety Goals
Goal: Improve the safety of using medications.
 Remove concentrated electrolytes (including, but not
limited to, potassium chloride, potassium phosphate,
sodium chloride >0.9%) from patient care units.
 Standardize and limit the number of drug
concentrations available in the organization.
 Identify and, at a minimum, annually review a list of
look-alike/sound-alike drugs used in the organization,
and take action to prevent errors involving the
interchange of these drugs.
JCAHO hospital safety goals
Goal: Improve the safety of using
infusion pumps.
 Ensure free-flow protection on all
general-use and PCA (patient
controlled analgesia) intravenous
infusion pumps used in the
organization.
JCAHO hospital safety goals
Goal: Reduce the risk of health careassociated infections.
 Comply with current Centers for Disease
Control and Prevention (CDC) hand hygiene
guidelines.
 Manage as sentinel events all identified
cases of unanticipated death or major
permanent loss of function associated with
a health care-associated infection.
Indications for Hand Washing
 Contact with a patient’s intact skin
 Contact with environmental surfaces
in the immediately vicinity of patients
 After glove removal
JCAHO hospital safety goals
Goal: Accurately and completely reconcile medications
across the continuum of care.
 During 2005, for full implementation by January 2006,
develop a process for obtaining and documenting a
complete list of the patient's current medications upon
the patient's admission to the organization and with the
involvement of the patient. This process includes a
comparison of the medications the organization
provides to those on the list.
 A complete list of the patient's medications is
communicated to the next provider of service when it
refers or transfers a patient to another setting, service,
practitioner or level of care within or outside the
organization.
JCAHO hospital safety goals
Goal: Reduce the risk of patient
harm resulting from falls.
 Assess and periodically reassess
each patient's risk for falling,
including the potential risk
associated with the patient's
medication regimen, and take
action to address any identified
risks.
14 Priority Focus Areas
 Assessment and Care/Services
 Communication*
 Credentialed Practitioners
 Appropriate Life Support certifications
 Valid permit or Texas license
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Equipment Use
Infection Control
Information Management*
Medication Management*
Priority Focus Areas (cont.)
Organizational Structure
Orientation and Training
Patient Safety
Physical Environment
Quality Improvement Expertise and
Activity*
 Rights and Ethics
 Staffing
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* Particular focus
Priority Focus Process
 Converts pre-survey data into:
 information to focus survey activities,
 increase consistency in the survey process,
 customize the accreditation process.
Tracer Methodology
Scott and White prepared for Tracer
Methodology by:
 Inviting a Consultant team from Joint
Commission Resources: physician,
nurse, and administrator
 Nominating 48 S&W staff to be trained
 Offering a day of didactic presentation &
one half day of a tracer demonstration
Demonstration Tracer Findings
 Food in all patient care areas
 Fragmented medical records with
documents missing
 No hand washing
 Staff unaware of unit/clinic results on
performance measures
 Unsecured medications
Performance Measures
Percent of Heart Attack Patients Given ACE Inhibitor
for LVSD
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
75%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 71%
 SCOTT & WHITE MEMORIAL
HOSPITAL 81%
Performance Measures
Percent of Heart Attack Patients Given Adult Smoking
Cessation Advice/Counseling
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
75%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 73%
 SCOTT & WHITE MEMORIAL
HOSPITAL 91%
Performance Measures
Percent of Heart Attack Patients Given Aspirin at
Arrival
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
91%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 90%
 SCOTT & WHITE MEMORIAL
HOSPITAL 93%
Performance Measures
Percent of Heart Attack Patients Given Aspirin at
Discharge
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
86%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 85%
 SCOTT & WHITE MEMORIAL
HOSPITAL 96%
Performance Measures
Percent of Heart Attack Patients Given Beta Blocker at
Arrival
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
84%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 81%
 SCOTT & WHITE MEMORIAL
HOSPITAL 97%
Performance Measures
Percent of Heart Attack Patients Given PTCA Received
Within 90 Minutes Of Arrival
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
37%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 38%
 SCOTT & WHITE MEMORIAL
HOSPITAL No data
Performance Measures
Percent of Heart Attack Patients Given Thrombolytic
Agent Received Within 30 Minutes Of Arrival
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
37%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 28%
 SCOTT & WHITE MEMORIAL
HOSPITAL No data
Performance Measures
Percent of Heart Failure Patients Given ACE Inhibitor
for LVSD
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
74%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 73%
 SCOTT & WHITE MEMORIAL
HOSPITAL 76%
Performance Measures
Percent of Heart Failure Patients Given Adult
Smoking Cessation Advice/Counseling
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
65%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 62%
 SCOTT & WHITE MEMORIAL
HOSPITAL 44%
Performance Measures
Percent of Heart Failure Patients Given Assessment of
Left Ventricular Function
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
78%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 72%
 SCOTT & WHITE MEMORIAL
HOSPITAL 92%
Performance Measures
Percent of Heart Failure Patients Given Discharge
Instructions
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
45%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 42%
 SCOTT & WHITE MEMORIAL
HOSPITAL 17%
Performance Measures
Percent of Pneumonia Patients Given Adult Smoking
Cessation Advice/Counseling
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
61%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 58%
 SCOTT & WHITE MEMORIAL
HOSPITAL 26%
Performance Measures
Percent of Pneumonia Patients Given Blood Cultures
Performed Before First Antibiotic Received
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
82%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 79%
 SCOTT & WHITE MEMORIAL
HOSPITAL 83%
Performance Measures
Percent of Pneumonia Patients Given Initial Antibiotic
Timing
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
72%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 70%
 SCOTT & WHITE MEMORIAL
HOSPITAL 55%
Performance Measures
Percent of Pneumonia Patients Given Oxygenation
Assessment
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
98%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 97%
 SCOTT & WHITE MEMORIAL
HOSPITAL 98%
Performance Measures
Percent of Pneumonia Patients Given Pneumococcal
Vaccination
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
43%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS EASTERN & SOUTHERN 38%
 SCOTT & WHITE MEMORIAL
HOSPITAL 27%
Accreditation Decision Options
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Accredited
Provisional Accreditation
Conditional Accreditation
Preliminary Denial of Accreditation
Denial of Accreditation
Immediate Threat to Life
Demonstration Tracer Results
 Scott and White would have failed
Triaging JCAHO Standards
 “A” List
 Must do: no question, no debate
 “B” List
 Must do: can be modified to
accommodate S&W practices
 “C” List
 Should do: JCAHO standards which, if
not met, will result in demerits but
not loss of accreditation
“A” List Examples
 Remove all food in patient care work
areas
 Follow CDC guidelines for hand washing
 Use of only approved abbreviations
 Have qualified staff and equipment for
patient population served
 Practice time outs prior to surgery and
other invasive procedures to verify right
patient, right procedure, right site
The End
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Please proceed to the post test
Download the post test
Complete the post test
Return the post test to Dr. S.K. Oliver
407i TAMUII
Post test question 1
Indications for handwashing include all
of the following except:
A. Contact with a patient’s intact skin
B. Contact with environmental surfaces
in the immediately vicinity of patients
C. After glove removal
D. Before entering a patient room
Post test question 2
Scott and White performed least well in
which of the following performance
areas:
A.
B.
C.
D.
Percent of Heart Attack Patients Given Aspirin at Arrival
Percent of Heart Attack Patients Given Beta Blocker at
Arrival
Percent of Heart Failure Patients Given Discharge
Instructions
Percent of Pneumonia Patients Given Blood Cultures
Performed Before First Antibiotic Received
Post test question 3
 Please rewrite this these orders:
1. 6.U Regular Insulin Now
_____________________________
1. Pot chloride 10 meq 1 po QID #90
______________________________