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Preparing for the JCIA
Consultation Survey
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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
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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
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How JCIA standards are spelled
out
Statement of
the standard
PFR.9.4 Informed consent is obtained before surgery, anesthesia, use of blood and
blood products, and other high-risk treatments and
procedures.
Intent
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
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.
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How to get ready for the
consultation survey
 AUBMC Mission Statement
 AUBMC policies & procedures
manual
 Departmental policies &
procedures manual
 AUBMC Safety/Emergency Plans
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Safety plan
Security plan
Hazardous material & waste
management plan
Emergency response plan
Fire safety plan
Medication equipment plan
Utility systems plan
Infection control manual
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Access & Continuity of Patient
Care:
  Admission of patients (ACC-MUL-001)
  Discharge of patients (ACC-MUL-002)
  Transfer of patients (ACC-MUL-003)
 Access to and sharing of Information about the
patient’s care among all staff providing care to
patients
 Multidisciplinary Assessment and Reassessment of Patients
(AOP-CLN-001)
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Patient and Family Rights
• Patient & family are informed of Patient Bill of
Rights and participation in care process.
 Patient handbook &posters around AUBMC
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Patient and Family Rights (cont’d)
• Confidentiality of information, security and privacy of patient.
 Confidentiality, Security, Privacy & Release of Patient Information (MOIMUL-002)
Confidentiality Guidelines:
• Do not allow medical information on computer terminals to be visible to
patients or other individuals not directly involved in the patients’ care.
• Exercise care when disposing of medical information.
• Do not place medical records or other medical information where they
can be easily accessed or removed by unauthorized persons.
• Speak softly over the phone and try to avoid excessive use of the
patient’s name.
• Do not discuss patient information with anyone in a social conversation.
• Exercise privacy when addressing patients.
• Do not discuss the reason for the patient’s visit in the waiting area or in
the presence of others.
• Do not disclose results of tests to individuals not directly involved in the
patients’ care.
• Do not reveal to unauthorized persons that a patient is, has been, or will
be admitted to AUBMC.
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Patient and Family Rights (cont’d)
Guidelines on Handling of Complaints at AUBMC
1. Try to resolve the complaint, if unresolved
2. Refer to the chairperson/department head
3. Nursing - related complaints - Director For Nursing
Services
3. Safety - Safety Officer
4. Others - Patient's Relations Office
Patient-care Complaints - Medical Center
Director/AUBMC Risk Manager
 Complaints & Complements Guidelines (GLD-ADM003)
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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.
 Patient Consent (PFR-MUL-001)
Mission Statement:
 AUBMC website & posted within AUBMC
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Quality Improvement and Patient
Safety
• PDCA Model, indicators, all staff participation
 PI Plan (QPS-MUL-002).
• Incident reporting, monitoring of errors.
 Patient-Related Risk Management Plan (QPSMUL-001)
Prevention and Control of Infection
 Hand Hygiene
 The hospital wide PCI Manual is still under
development by the Infection Control Program.
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Governance Leadership and
Direction
Departmental Policy and Procedure Manual, know the content
Subject
1.
Department mission statement (optional)
2.
Scope of services and hours of operation
3.
Organization structure (represented in an organization
chart and authority matrix)
4.
Physical facilities (including physical layout and major
equipment)
5.
Safety and infection control procedures (in coordination
with the Occupational Safety Officer and the Infection
Control Program)
6.
Internal performance improvement plan (selection and
monitoring of indicators)
7.
Departmental orientation program
8.
Internal (operating) policies and procedures
Page number
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Safety Plans
  Fire Safety plan
 No smoking policy within AUBMC
 Smoking Policy
 Preparing, testing and responding to disasters
 Disaster plan
 Hazardous materials inventory, handling,
storage, use and the control and disposal of
hazardous materials and waste.
●
Handling spills in your workplace
 hazardous materials
 Regular staff education, training and
documentation regarding safety plans
 Training, testing & documentation of staff who
operate & maintain medical & utility equipment
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Facility Management and Safety
(manual under construction)
• Fire safety: RACE, PASS, 5555
• Disaster plan: 9999, participation in drills
• Security: safegaurd children and
vulnerable patients.
• Equipment management: training on new
equipment, ensure functionality before
patient use.
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Staff Qualifications
& Education
• Job description: Each staff member’s
responsibilities are defined.
 HR Policy & Procedure Manual, Competency
Management (SQE-HRD-001)
• Staff evaluation according to job
description: Performance appraisal process
done yearly.
 Orientation Plan (SQE-HRD-004), Performance
 Appraisal Policy (under development)
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Patient Medical Record
 Records and information are protected from
loss, destruction, tampering, and unauthorized
access or use.
 Health care providers have access to the
information in a patient’s clinical record each
time the patient is seen for a new or continuing
care episode.
 Medical Record Content and Documentation
(MOI-MUL-003)
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2007 International Patient Safety
Goals
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2007 International Patient Safety Goals
Poster
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Goal #1: Identify Patients Correctly
Patient room number should not be
used for patient identification.
Patient Identification Policy
COP-MUL-009
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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.
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Goal #3: Improve the Safety of
High-Alert Medications
Nursing & Pharmacy
Committee is
working on the list of
high alert
medications.
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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.
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Goal #5: Reduce the Risk of Health
Care-Associated Infections
All AUBMC Personnel shall use proper
hand hygiene before:
● Patient contact
● Applying gloves before starting
any patient related procedure
such as: central- venous catheters
(CVC), inserting urinary catheters,
peripheral vascular catheters, or
other invasive devices that do not
require surgery
● Eating, drinking, preparing or
handling food
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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.
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