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1 © Copyright, Joint Commission International International Patient Safety Goals (IPSG) Improving Patient Safety means . . . Reducing Patient Harm Client name/ Presentation Name/ 12pt - 2 © Copyright, Joint Commission International Reducing Medical Errors Challenges for Patient Safety Leadership Move toward a more safety-oriented culture Practice proactive systems analysis & risk reduction Standardize processes and equipment Ensure adequate and effective staffing Implement team training for all staff Encourage and support patient involvement Client name/ Presentation Name/ 12pt - 3 © Copyright, Joint Commission International Promote effective communication Systems Analysis in Health Care To identify vulnerabilities and hazardous conditions that could (and, over time, will) impact patient safety and quality of care. To focus the redesign of those systems and processes to improve patient safety and quality of care. Client name/ Presentation Name/ 12pt - 4 © Copyright, Joint Commission International A systematic evaluation of a health care organization’s systems and processes: Represents proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts Incorporating these new tools into our accreditation requirements is a significant step Organizations taking responsibility for using the IPSG to foster an atmosphere of continuous improvement is even more important Client name/ Presentation Name/ 12pt - 5 © Copyright, Joint Commission International Implementation of IPSG…. PSG 1 PSG 2 PSG 3 PSG 4 PSG 5 PSG 6 Identify Patients Correctly Improve Effective Communication Improve the Safety of High-Alert Medications Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery Reduce the Risk of Health Care Associated Infections Reduce the Risk of Patient Harm Resulting from Falls Client name/ Presentation Name/ 12pt - 6 © Copyright, Joint Commission International JCI 4th Edition International Patient Safety Goals A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification Use at least two (2) ways to identify a patient: • • • • • giving medications giving blood and blood products taking blood samples taking other samples for clinical testing providing treatment or procedure The patient’s Room Number cannot be used as an identifier Client name/ Presentation Name/ 12pt - 7 © Copyright, Joint Commission International IPSG.1 Identify Patients Correctly The complete VO and TO or test result is written down by the receiver of the order or test result. Must use a verification “read back” of complete order or test result The order or test result is confirmed by the individual who gave the order or test result Policies and procedures support consistent practice verifying the accuracy of verbal and telephone communications Client name/ Presentation Name/ 12pt - 8 © Copyright, Joint Commission International IPSG 2: Improve Effective Communication Policies/procedures are developed to address identification, location, labeling and storage of high-alert medications Policies/procedures are implemented Concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that restricts access Client name/ Presentation Name/ 12pt - 9 © Copyright, Joint Commission International IPSG 3: Improve Safety of High Alert Medications – Has to be supported by evidence – Is the substance really needed very quickly? – If it is used to dilute, is the diluted solution available? Client name/ Presentation Name/ 12pt - 10 © Copyright, Joint Commission International Clinical Necessity Collaboratively develop a policy/procedure that includes: Definition of surgery that incorporates at least those procedures that investigate and/or treat diseases and disorders of the human body through cutting removing, altering, or insertion of diagnostic/therapeutic scopes. Client name/ Presentation Name/ 12pt - 11 © Copyright, Joint Commission International IPSG 4: Ensure Correct-site, Correct-procedure, Correctpatient Surgery IPSG 4 Correct Site, Procedure and Patient – Use an instantly recognizable mark for surgical site identification – Involves the full surgical team and is documented just before starting a surgical procedure – Policies/procedures are developed to support uniform process to ensure correct site, procedure, and patient (including medical and dental procedures done in settings other than the operating theater) Client name/ Presentation Name/ 12pt - 12 © Copyright, Joint Commission International – Involves the patient in the marking process Checklist or other process to verify: DOCUMENTS EQUIPMENT PATIENT Functional & Correct PROCEDURE Client name/ Presentation Name/ 12pt - 13 © Copyright, Joint Commission International SURGERY SITE – The organization has adopted or adapted currently published and generally accepted hand-hygiene guidelines – Implements an effective hand-hygiene program – Policies/procedures are developed that support continued reduction of health care associated infections Need data to demonstrate effectiveness Client name/ Presentation Name/ 12pt - 14 © Copyright, Joint Commission International PSG 5: Reduce the Risk of Health Care-Associated Infections Implements a process for the initial assessment of patient for fall risk and reassessment of patients when indicated by a change in condition or medications, among others Measures are implemented to reduce falls risk for those at risk Client name/ Presentation Name/ 12pt - 15 © Copyright, Joint Commission International IPSG 6: Reduce the Risk of Patient Harm resulting from Falls – Measures are monitored for results, both successful fall injury reduction and any unintentional related consequences – Policies/procedures support continued reduction of risk of patient harm resulting from falls in the organization Client name/ Presentation Name/ 12pt - 16 © Copyright, Joint Commission International IPSG 6 Reducing Risk of Harm Resulting from Falls Client name/ Presentation Name/ 12pt - 17 © Copyright, Joint Commission International Next Presentation 18 © Copyright, Joint Commission International Access to Care and Continuity of Care (ACC) 1. 2. 3. 4. 5. Admission to the Organization Continuity of Care Discharge, Referral, and Follow-up Transfer of Patients Transportation Client name/ Presentation Name/ 12pt - 19 © Copyright, Joint Commission International ACC-Five Areas of Focus – Screening at point of first contact – Determine if care can be provided – Diagnostic test are available for decision making-standardized by policy – Patients are informed if any wait or delay and reasons (waiting list) Client name/ Presentation Name/ 12pt - 20 © Copyright, Joint Commission International ACC.1 “ADMISSION” of In-Patients & “REGISTRATION” of Out-Patients – Policies & Procedures (PP) standardize admission and registration for out-patients and in-patients – PP Admitting emergency patients – PP Holding patients for observation – PP Managing patients when bed space not available Client name/ Presentation Name/ 12pt - 21 © Copyright, Joint Commission International ACC.1.1 Process of Admission or Registration – Evidence based triage process is used to prioritize patients with immediate needs – Staff are trained use of the triage process – Staff prioritize patients based on urgency of needs – Emergency patients are assessed and stabilized prior to transfer Client name/ Presentation Name/ 12pt - 22 © Copyright, Joint Commission International ACC.1.1.1 Emergency Patients ACC.1.1.2 Needs are Prioritized for In-patients – – – – Preventative Palliative Curative Rehabilitative Client name/ Presentation Name/ 12pt - 23 © Copyright, Joint Commission International – Screening assessment identifies patient’s needs – Services or units are selected to meet needs based on the assessment: – In-patients and out-patients are informed of delays – Reason for delay and available alternatives – Documented in the patient medical record – Written policies/procedures Client name/ Presentation Name/ 12pt - 24 © Copyright, Joint Commission International ACC.1.1.3 Waiting Periods or Delays – Patient and Family receive information during the admission process on: – Proposed care – Expected out comes of care – Expected costs – Sufficient information to make knowledgeable decisions Client name/ Presentation Name/ 12pt - 25 © Copyright, Joint Commission International ACC.1.2 Information Provided ACC.1.3 Reduction of Barriers – Leaders and staff identify most common barriers for patients Physical Language Cultural Other – A process is identified and implemented – to overcome or limit identified barriers – to limit impact of barriers on delivery of services Client name/ Presentation Name/ 12pt - 26 © Copyright, Joint Commission International – – – – – Admission/transfer criteria established for Intensive and Specialized Units – Criteria are physiologic-based – Appropriate individuals are involved in developing and implementing the criteria – Patients meet the criteria (documented) – Patients are discharged/transferred when they no longer meet criteria Client name/ Presentation Name/ 12pt - 27 © Copyright, Joint Commission International ACC.1.4 Criteria for Admission or Transfer to Intensive Care – Leaders design and support continuity (coordination & resources) – Criteria or policies determine transfers within the organization – Continuity and coordination is evident throughout all phases of patient care and to the patient Client name/ Presentation Name/ 12pt - 28 © Copyright, Joint Commission International ACC.2 Continuity of Patient Care ACC.2.1 Individual Responsible – The individual documents the patient plan of care – Transfer from one individual to another is described in policy Client name/ Presentation Name/ 12pt - 29 © Copyright, Joint Commission International – There is an individual responsible for patient’s care who is – a physician or other person – qualified to assume responsibility for care – identified to the hospital staff ACC.3 Referral and Discharge Policy – Policy for the appropriate referral or discharge of patients – Policy guides patients “on pass” for a defined period of time Client name/ Presentation Name/ 12pt - 30 © Copyright, Joint Commission International – Based on patient’s needs for continuing care – The patient’s readiness for discharge – Discharge planning begins early and includes the family as appropriate – Discharge planning for both supportive and continuing medical services – Community providers, organizations and individuals are identified – Appropriate referrals are made (in the patient’s home community whenever possible) Client name/ Presentation Name/ 12pt - 31 © Copyright, Joint Commission International ACC.3.1 Cooperation with Community Practitioners ACC.3.2 Discharge Summary – In-patient clinical records contain a discharge summary prepared by a qualified individual – Follow up instructions – In the patient’s medical record – Given to the patient at discharge – Provided to practitioner responsible for continued care – Policy and procedure define discharge summary Client name/ Presentation Name/ 12pt - 32 © Copyright, Joint Commission International – Copies are: ACC.3.2.1 Discharge Summary – – – – – – – Reason for admission Significant physical and other findings Significant diagnoses and co-morbidities Diagnostic and therapeutic procedures Significant medication and treatments Condition at discharge Discharge medications and all medications to be taken at home – Follow up instructions Continued on next slide….. Client name/ Presentation Name/ 12pt - 33 © Copyright, Joint Commission International – Prepared at discharge, documented in the patient’s record and contains: ACC.3.2 Discharge Summary Client name/ Presentation Name/ 12pt - 34 © Copyright, Joint Commission International – Unless contrary to policy, laws, or culture, patients are given a copy – A copy is provided to the practitioner responsible for patient’s continuing or followup care – Identify which continuing care patients require a summary – Identify how the summary is maintained and who maintains it – Identify format and content of summary – Define what is considered current – Policy for completed summary Client name/ Presentation Name/ 12pt - 35 © Copyright, Joint Commission International ACC.3.3 Out Patient Summary of Continuing Care ACC.3.4 Understandable Follow Up Instructions – Follow up instructions are understandable Client name/ Presentation Name/ 12pt - 36 © Copyright, Joint Commission International – Return for follow up care – When to obtain urgent care – Care necessary to patient’s condition – Process for management and follow up of in-patients and outpatients who leave AMA – Known family physicians are notified – Applicable with local laws and regualtions Client name/ Presentation Name/ 12pt - 37 © Copyright, Joint Commission International ACC.3.5 Against Medical Advice ACC.4 Transfer Policy – Patient’s need for continuing care – Transfer of responsibility to another provider or setting – Who is responsible during transfer – Situations where transfer is not possible Client name/ Presentation Name/ 12pt - 38 © Copyright, Joint Commission International – Guiding process for transferring patients to include: ACC.4.1 Referring and Receiving Organizations Client name/ Presentation Name/ 12pt - 39 © Copyright, Joint Commission International – Referring organization determines whether receiving organization can meet patient’s needs – Arrangements (formal or informal) are in place when patients are frequently transferred ACC.4.2 Written Summary – Patient status – Procedures – Other interventions provided – Patient’s continuing care needs Client name/ Presentation Name/ 12pt - 40 © Copyright, Joint Commission International – Clinical summary is transferred with patient & includes: – All patients are monitored during direct transfer – Qualifications of the staff member doing the monitoring are appropriate for patient’s condition Client name/ Presentation Name/ 12pt - 41 © Copyright, Joint Commission International ACC.4.3 Monitoring Patients During Transfer ACC.4.4 Documentation of Transfer – Name of organization and individual agreeing to receive patient – Reason for transfer – Any special conditions related to transfer – Any change of patient’s condition or status during transfer – Any other notes require by the transferring organization Client name/ Presentation Name/ 12pt - 42 © Copyright, Joint Commission International – Documentation includes: – Assessment of transportation needs when referring patients – Transportation is arranged appropriate to patient needs – Owned transport vehicles meet laws and regulations – Contracted transportation meets patient needs – Appropriate equipment – Monitoring the quality and safety or transportation – Includes a complaint process Client name/ Presentation Name/ 12pt - 43 © Copyright, Joint Commission International ACC.5 Planning Transportation Needs Client name/ Presentation Name/ 12pt - 44 © Copyright, Joint Commission International Next Presentation 45 © Copyright, Joint Commission International Patient and Family Rights (PFR) 1. Identify, Protect and Promote Patient Rights 2. Inform Patients of Their Rights Including Patient’s Family in Decisions 3. Informed Consent 4. Research 5. Organ Donation Client name/ Presentation Name/ 12pt - 46 © Copyright, Joint Commission International PFR – Six Areas of Focus PFR.1 Processes Support Rights – Leaders – Staff members are knowledgeable and can explain their responsibilities – Policies and Procedures (PP) guide and support patient and family rights Continued on next slide Client name/ Presentation Name/ 12pt - 47 © Copyright, Joint Commission International – work collaboratively to protect and advance patient and family rights – understand rights as defined in laws and regulations PFR.1 Process Support Rights – to have the prerogative to determine what information is provided the family and others, – and under what circumstances. Client name/ Presentation Name/ 12pt - 48 © Copyright, Joint Commission International – The hospital respects patient rights, and in some cases the rights of patient’s family: – There is a hospital process to identify and to respect patient values and beliefs and those of the family – Staff members – use the process – provide care respectful of the patient’s values and beliefs Client name/ Presentation Name/ 12pt - 49 © Copyright, Joint Commission International PFR.1.1 Patient’s Values and Beliefs PFR.1.1.1 Spiritual Support – There is a process to respond to requests for religious or spiritual support – Process is designed to accommodate: Client name/ Presentation Name/ 12pt - 50 © Copyright, Joint Commission International – Routine requests – Complex requests PFR.1.2 Patient Privacy – Clinical interviews – Examinations – Procedures/treatments – Transport Client name/ Presentation Name/ 12pt - 51 © Copyright, Joint Commission International – Staff members identify patient expectations and needs for privacy – The patient’s expressed need for privacy is respected in all: – The hospital defines to what extent it is responsible for patient’s possessions – Patients are informed of the hospital’s responsibility – Patient’s possessions are safeguarded when the hospital assumes responsibility or when the patient is unable to assume responsibility Client name/ Presentation Name/ 12pt - 52 © Copyright, Joint Commission International PFR.1.3 Patient Possessions – There is a process to protect patients from assault – Those addressed in the process are: – Infants, Vulnerable children, Elderly – Others unable to protect themselves – Individuals without identification are investigated – Remote or isolated areas are monitored Client name/ Presentation Name/ 12pt - 53 © Copyright, Joint Commission International PFR.1.4 Physical Assault PFR.1.5 Appropriate Protection – Children, disabled individuals, elderly – Others identified by the hospital – Staff members understand their responsibilities for protection Client name/ Presentation Name/ 12pt - 54 © Copyright, Joint Commission International – Leaders identify vulnerable patient groups – Those protected include: PFR.1.6 Confidential Information – How their information will be kept confidential and about laws and regulations that require the release and/or require confidentiality of patient information – Patients are requested to grant permission to release information not covered by law and regulation Client name/ Presentation Name/ 12pt - 55 © Copyright, Joint Commission International – Patients are informed about: – Policies support and promote patient and family participation in care processes – Policies and procedures address the right to seek a second opinion without fear of compromised care – Staff members are trained on their role in supporting participation in care processes Client name/ Presentation Name/ 12pt - 56 © Copyright, Joint Commission International PFR.2 Participation in Care PFR.2.1 Patient Information – medical conditions and any confirmed diagnosis – planned care and treatment – when consents will be requested and the process used – their right to participate in care decisions Client name/ Presentation Name/ 12pt - 57 © Copyright, Joint Commission International – Patients & families understand how and when they will be told about PFR.2.1.1 Outcomes of Care – how they will be told and who will tell them of the outcomes of care and treatment – how they will be told and who will tell them of any unanticipated outcomes of care and treatment (out come of treatment including unanticipated outcome) Client name/ Presentation Name/ 12pt - 58 © Copyright, Joint Commission International – Patients and families understand PFR.2.2 Right to Refuse or Discontinue Care – their rights to refuse or discontinue care – the consequences of their decisions – their responsibilities related to such decisions – available care and treatment alternatives Client name/ Presentation Name/ 12pt - 59 © Copyright, Joint Commission International – Patient and families will understand: PFR.2.3 Withholding Resuscitation/ Withdrawing Life Support – Hospital defines its position – Hospital’s position conforms to: – Community’s religious and cultural norms – Any legal or regulatory requirements – How to make their decisions known – How to modify decisions during care – Policies & procedures guide: – Hospital’s response to patient’s decisions – Documentation about decisions – The ethical and legal issues related to carrying out the patient’s wishes Client name/ Presentation Name/ 12pt - 60 © Copyright, Joint Commission International – Policies guide patients on: – The organization respects and supports the patient’s right to appropriate assessment and management of pain – Staff understand the personal, cultural, and social influences on the patients right to: – report pain – accurately assess and manage pain Client name/ Presentation Name/ 12pt - 61 © Copyright, Joint Commission International PFR.2.4 Assessment of Pain PFR.2.5 End of Life Care Client name/ Presentation Name/ 12pt - 62 © Copyright, Joint Commission International – Hospital staff recognizes that dying patients have unique needs – Staff respects the right of dying patients to have those unique needs addressed in the care process PFR.3 Complaints and Conflicts – complaints – dilemmas that arise during care – PP identify – participants in the process – how the patient and family participate Client name/ Presentation Name/ 12pt - 63 © Copyright, Joint Commission International – Patients are aware of their right to voice a complaint and the process to do so – The hospital has and uses a mechanism to review: PFR.4 Education of Staff – their role in identifying patient and family values and beliefs – how these values and beliefs can be respected in the care process – their role in protecting patient and family rights Client name/ Presentation Name/ 12pt - 64 © Copyright, Joint Commission International – Staff members understand: – Patients receive information about their rights in writing – The hospital has a process to inform patients or families of their rights when written communication is not effective or appropriate – Language – Illiteracy – Medical condition Client name/ Presentation Name/ 12pt - 65 © Copyright, Joint Commission International PFR.5 Patients are Informed of Rights PFR.6 Patients Receive Information Client name/ Presentation Name/ 12pt - 66 © Copyright, Joint Commission International – Policy and procedure contain a clearly defined informed consent process – Patients give consent consistently with policy – Designated staff are trained consistently with policy PFR.6.1 Adequate Information – their condition – proposed procedures and treatments and who is authorized to perform them – potential benefits and drawbacks and possible problems related to recovery – alternatives to the proposed treatment and results of possible non–treatment – likelihood of success of treatments – Patients know the identify of the physician or practitioner responsible for their care Client name/ Presentation Name/ 12pt - 67 © Copyright, Joint Commission International – Patients are informed about: – The hospital has a process for when others can grant informed consent – The process is consistent with law, culture, and custom – The individual giving consent is documented in the patient’s record Client name/ Presentation Name/ 12pt - 68 © Copyright, Joint Commission International PFR.6.2 Others Giving Consent PFR.6.3 General Consent – the scope of a General Consent is clear – the General Consent is documented per hospital policy – However, the standards do not require a General Consent Client name/ Presentation Name/ 12pt - 69 © Copyright, Joint Commission International – If General Consent is obtained at the time of admission or registration for the first time as an out-patient, then: PFR.6.4 Required Informed Consents – – – – – Surgical or invasive procedures Anesthesia other than local Moderate (“conscious”) and deep sedation Blood and blood products High-risk procedures and treatments – Required documentation in the medical record: – Identity of the individual providing information to patient and family – Patient’s signature or a record of verbal consent Client name/ Presentation Name/ 12pt - 70 © Copyright, Joint Commission International – Consent is obtained before: – The hospital has a list of those operations, procedures, and treatments that require a separate consent – The list is developed collaboratively by physicians and others that provide the treatments and perform the procedures Client name/ Presentation Name/ 12pt - 71 © Copyright, Joint Commission International PFR.6.4.1 Specific Consents PFR.7 Access to Research – – – – – Expected benefits Potential discomforts and risks Alternatives that might help them Procedures that must be followed Refusal to participate or withdraw will not compromise their access to services – Relevant only if research is done in the hospital Client name/ Presentation Name/ 12pt - 72 © Copyright, Joint Commission International – Patients who may benefit from participating in research are identified and informed about how to gain access to research – Patients asked to participate are informed about: PFR.7.1 Research Patients are Protected – Reviewing research protocols – Weighing the benefits and risks – Obtaining consent – Withdrawing from participation Client name/ Presentation Name/ 12pt - 73 © Copyright, Joint Commission International – Patients and families are informed about the hospital’s process for: – Informed consent is obtained when the patient decides to participate – Consent decisions are documented, dated – The individual providing the information is documented in the patient’s record – Consent is documented in the medical record by signature of the patient or record of verbal consent Client name/ Presentation Name/ 12pt - 74 © Copyright, Joint Commission International PFR.8 Informed Consent for Research PFR.9 Oversight of Research – A clear statement of the purpose of oversight activities – A review process – A process to weigh relative risks and benefits – Processes to provide confidentiality and security of research information Client name/ Presentation Name/ 12pt - 75 © Copyright, Joint Commission International – The organization has a committee or other mechanism to oversee research: – Oversight includes: PFR.10 Organ Donation – The hospital Client name/ Presentation Name/ 12pt - 76 © Copyright, Joint Commission International – supports patient and family choices to donate organs and other tissue – provides information to support the choice PFR.11 Oversight – Policy and procedure guide: – the procurement and donation process – the transplantation process – in the policy – in the issues and concerns related to organ donation and the availability of transplants – The hospital cooperates with the relevant organizations and agencies in the community to respect and implement choices to donate Client name/ Presentation Name/ 12pt - 77 © Copyright, Joint Commission International – Staff is trained: Client name/ Presentation Name/ 12pt - 78 © Copyright, Joint Commission International Next Presentation 79 © Copyright, Joint Commission International Assessment of Patients (AOP) 1. Collecting and Analyzing Patient Data and Information 2. Laboratory Services 3. Radiology and Diagnostic Imaging Services Client name/ Presentation Name/ 12pt - 80 © Copyright, Joint Commission International AOP – Three Areas of Focus AOP.1 – AOP.1.1 Assessment Process – AOP.1 Hospital PP: – AOP.1.1 The scope and content of assessments are defined in policies: – For each clinical discipline – For inpatient and outpatient settings Client name/ Presentation Name/ 12pt - 81 © Copyright, Joint Commission International – define the assessment information to be obtained for – inpatients – outpatients – identify the information to be documented for the assessments AOP.1.2 Initial Assessment – Inpatients and outpatients have an initial assessment that meets hospital policy (Note that by AOP.1 and 1.1, inpatient and outpatient assessments may be very different) – A medical assessment including a health history and physical examination – A psychological assessment appropriate to needs – Social and economic as appropriate to needs Continued on next slide Client name/ Presentation Name/ 12pt - 82 © Copyright, Joint Commission International – Initial assessment includes, according to hospital policy: AOP.1.2 Initial Assessment – The initial assessment results in: Client name/ Presentation Name/ 12pt - 83 © Copyright, Joint Commission International – Understanding any previous care and the care the patient is currently seeking – Selecting the best setting for the care – An initial diagnosis AOP.1.3 Patient’s Needs Identified – The initial assessment results in: – Medical needs are identified based on the documented H&P and other required hospital assessments – Nursing needs are identified based on the nursing assessment, the medical assessment and other required hospital assessments Client name/ Presentation Name/ 12pt - 84 © Copyright, Joint Commission International – Identification of patient’s medical needs – Identification of patient’s nursing needs AOP.1.3.1 Assessment of Emergency Patients – Emergency patients have: – If emergency surgery is performed, the following are recorded before the operation: – A brief assessment note – A preoperative diagnosis Client name/ Presentation Name/ 12pt - 85 © Copyright, Joint Commission International – Medical assessment appropriate to their needs and condition – Nursing assessment appropriate to their needs and condition – Assessment time frames are established for all settings and services – The initial medical and nursing assessments are conducted within the first 24 hours or earlier as indicated by the patient’s condition or hospital policy (AOP.1.4.1) – Assessments are completed in the established time frames – Assessments from outside the organization are reviewed/verified at the time of admission to inpatient status Client name/ Presentation Name/ 12pt - 86 © Copyright, Joint Commission International AOP.1.4 – AOP.1.4.1 Time Frames AOP.1.4.1 Assessments Performed Before Admission – For any assessment conducted more than 30 days prior to: the medical history has been updated and the physical examination repeated – For any assessment less than 30 days old, any significant changes in the patient’s condition are noted at the time of admission to inpatient status Client name/ Presentation Name/ 12pt - 87 © Copyright, Joint Commission International – admission to inpatient status or – an outpatient procedure AOP.1.5 Assessments are Available – For other than medical and nursing assessments, there can be a summary note in the patient’s record, with a fuller description in the concerned department as long as there is access to them (see Intent Statement) Client name/ Presentation Name/ 12pt - 88 © Copyright, Joint Commission International – Assessments are documented in the patient’s medical record – Individuals caring for the patient can find and retrieve assessments as needed – Medical and nursing assessments are documented within 24 hours of admission – Medical assessment is performed prior to surgery – Medical assessment is documented prior to surgery Client name/ Presentation Name/ 12pt - 89 © Copyright, Joint Commission International AOP.1.5.1 Assessments before Anesthesia or Surgery – Qualified individuals develop criteria to identify patients who require further nutritional and/or functional assessment – Patients are screened for nutritional risk and/or functional risk as part of the initial assessment – Patients identified for additional assessment based on the criteria that identifies additional needs, receive additional assessments for nutritional and/or functional needs – (Functional risk means having one or more skill needed for the activities of daily living impaired) Client name/ Presentation Name/ 12pt - 90 © Copyright, Joint Commission International AOP.1.6 Nutritional and Functional Screening AOP.1.7 Special Populations – Very young patients – Frail elderly – Terminally ill and others in pain – Women in labor – Those with emotional or psychiatric disorders – Those suspected of drug and/or alcohol dependency – Victims of abuse and neglect – The initial assessment is for these populations is modified (i.e. patients belonging to these special populations receive individualized assessments) 91 Client name/ Presentation Name/ 12pt - 91 © Copyright, Joint Commission International – The hospital identifies special populations, including at least: – When the need for additional specialized assessments are identified, patients are referred within or outside the organization, as appropriate – Additional specialized assessments completed within the organization are documented Client name/ Presentation Name/ 12pt - 92 © Copyright, Joint Commission International AOP.1.8 Specialized Assessments AOP.1.9 Dying Patients and Their Families Client name/ Presentation Name/ 12pt - 93 © Copyright, Joint Commission International – Dying patients and their families are assessed and reassessed – Findings guide care and services – Findings are documented AOP.1.10 Specialized Assessments Client name/ Presentation Name/ 12pt - 94 © Copyright, Joint Commission International – Patients are referred within the organization when the need for specialized assessments are identified – Completed and documented AOP. 2 Reassessment – Patients are reassessed: Continued on next slide Client name/ Presentation Name/ 12pt - 95 © Copyright, Joint Commission International – To determine their response to treatment – To plan for continued treatment or discharge – At intervals appropriate to their condition, plan of care and individual needs and hospital PP AOP. 2 Reassessment – A physician reassesses patients daily during acute phase of care – Daily means including weekends and holidays – Circumstances, types of patients, or patient populations (i.e. define non-acute population) – Policy identifies the reassessment interval for these patients – All reassessments are documented Client name/ Presentation Name/ 12pt - 96 © Copyright, Joint Commission International – Policy defines when physician reassessment less often than daily is acceptable based on: AOP.3 Qualified Individuals – Only those permitted by licensure, applicable laws and regulations or certifications can perform the assessments – Emergency assessments are conducted by identified and qualified individuals – Nursing assessments are conducted by identified and qualified individuals – Those qualified to conduct assessments and reassessments have their responsibilities defined in writing (by clinical privilege or job description) Client name/ Presentation Name/ 12pt - 97 © Copyright, Joint Commission International – Individuals qualified to assess and reassess are identified by the hospital – Patient assessment data and information are analyzed and integrated – Those responsible for the patient’s care participate in the process Client name/ Presentation Name/ 12pt - 98 © Copyright, Joint Commission International AOP.4 Collaboration to Integrate Assessments AOP.4.1 Patient Needs Prioritized – The outcomes of the assessments and any confirmed diagnosis as appropriate – The planned care and treatment and participate in the decisions about the priority needs Client name/ Presentation Name/ 12pt - 99 © Copyright, Joint Commission International – Patient needs are prioritized based on assessment results – Patients and families are informed of: AOP.5 Laboratory Services – Laboratory services – Emergency laboratory services are available – Outside services are selected based on acceptable compliance with laws and regulations – Patients are informed about any relationships between the referring physician and outside laboratory services Client name/ Presentation Name/ 12pt - 100 © Copyright, Joint Commission International – meet applicable local and national standards, laws and regulations – are adequate, regular, and convenient – Laboratory safety program is – in place and is appropriate to the risks and hazards – coordinated with the hospital safety management program – PP address the handling and disposal of infectious and hazardous material – Safety devices are available and appropriate – Staff are oriented to the safety program – Staff receive education – for new procedures – for newly acquired or recognized hazardous materials Client name/ Presentation Name/ 12pt - 101 © Copyright, Joint Commission International AOP.5.1 Lab Safety Program AOP.5.2 Staff Training for Testing – Administer tests – Interpret tests – Are adequate in numbers to meet needs – Supervisory staff have appropriate training and experience Client name/ Presentation Name/ 12pt - 102 © Copyright, Joint Commission International – Staff who perform testing and those who supervise are identified – Appropriately trained and experienced staff: AOP.5.3 Laboratory Results Timing – Expected report time for results has been established – Timeliness of reporting urgent/emergency tests is monitored – Tests are reported within a time frame to meet patient needs Client name/ Presentation Name/ 12pt - 103 © Copyright, Joint Commission International – (Established collaboratively – see GLD.5.1.1, MCI.5) AOP.5.3.1 Critical Results Client name/ Presentation Name/ 12pt - 104 © Copyright, Joint Commission International – Collabortive method used to develop processes for reporting critical results – Define critical test values AOP.5.4 Equipment Maintenance – – – – – – Selecting and acquiring equipment Inventorying equipment Inspecting and testing equipment Calibrating and maintaining equipment Monitoring and follow-up Adequately documenting the above requirements Client name/ Presentation Name/ 12pt - 105 © Copyright, Joint Commission International – Laboratory equipment management is implemented – The program includes: AOP.5.5 Available Reagents – Identified – Available – Stored and dispensed according to guidelines – Evaluated for accuracy and results – Completely and accurately labeled according to guidelines Client name/ Presentation Name/ 12pt - 106 © Copyright, Joint Commission International – All reagents, supplies and solutions are: – Procedures for specimens guide: – Ordering tests – Collection and identification of specimens – Specimen transport, storage and preservation – Specimen receipt and tracking – Procedures are – implemented – observed when outside sources or service are used Client name/ Presentation Name/ 12pt - 107 © Copyright, Joint Commission International AOP.5.6 Specimen Handling – Reference ranges are established for each test – Ranges are: – Included in the clinical record when results are reported – Provided when tests are performed by outside sources – Appropriate to the hospital’s geography and demographics – Reviewed and updated as needed Client name/ Presentation Name/ 12pt - 108 © Copyright, Joint Commission International AOP.5.7 Test Ranges – Qualified individual(s) provide direction and oversight for all clinical laboratories – Responsibilities include: – Developing, implementing and maintaining policies and procedures – Administrative oversight – Quality Control (QC) programs – Recommending outside sources – Monitoring and reviewing all services within and outside the laboratory – This includes point of care testing (see Intent Statement) Client name/ Presentation Name/ 12pt - 109 © Copyright, Joint Commission International AOP.5.8 Qualified Director – The QC Program includes: – Validation of test methods – Daily surveillance of test results – Rapid correction of deficiencies – Testing of reagents – Documentation of results and corrective actions – The program is implemented Client name/ Presentation Name/ 12pt - 110 © Copyright, Joint Commission International AOP.5.9 Quality Control – Participation in a proficiency testing program or an alternative for all specialty laboratory services and tests – External QC is an acceptable alternative – A cumulative record of participation is maintained Client name/ Presentation Name/ 12pt - 111 © Copyright, Joint Commission International AOP.5.9.1 Proficiency Testing AOP.5.10 Outside Services – QC results from outside sources are regularly reviewed – Qualified individuals review the QC results – A roster of experts for specialized diagnostic areas is maintained – Experts in specialized areas are contacted when needed Client name/ Presentation Name/ 12pt - 112 © Copyright, Joint Commission International AOP.5.11 Experts – Radiology and diagnostic imaging services meet applicable local and national standards, laws and regulations – Adequate, regular and convenient services are available to meet needs – Emergency services are available after normal hours of operation Client name/ Presentation Name/ 12pt - 113 © Copyright, Joint Commission International AOP.6 Imaging Services – Outside services are selected based on recommendations of the director and an acceptable record of timely performance and compliance – Patients are informed about any relationships between referring physicians and recommended outside sources of radiology and diagnostic imaging services Client name/ Presentation Name/ 12pt - 114 © Copyright, Joint Commission International AOP.6.1 Referral for Diagnostic Imaging – Radiation Safety Program is in place and coordinated with the hospital’s safety and management program – The program includes radiology and diagnostic imaging services as well as radiation oncology and the cardiac catheterization laboratory (See Intent Statement) – Note that Nuclear Medicine is not mentioned; however, it is included by law or regulation in most countries Continued on next slide Client name/ Presentation Name/ 12pt - 115 © Copyright, Joint Commission International AOP.6.2 Radiation Safety Program AOP.6.2 Radiation Safety Program – PP address: – Radiation safety devices are available – Staff are oriented to – safety procedures and practices – new procedures and equipment hazards Client name/ Presentation Name/ 12pt - 116 © Copyright, Joint Commission International – Compliance with applicable standards and laws and regulations – Handling and disposal of infectious and hazardous materials (See also PCI.7.1, FMS.5) – Staff who perform diagnostic and imaging studies and those who supervise are identified – Appropriately trained and experienced staff: – perform studies – interpret study results – (who interprets X-rays from the ER after hours?) – verify and report results – are of adequate numbers – Supervisory staff have appropriate training and experience Client name/ Presentation Name/ 12pt - 117 © Copyright, Joint Commission International AOP.6.3 Imaging Staff Training – Expected report time for results has been established – Timeliness of reporting urgent/emergency tests is monitored – Tests are reported within a time frame to meet patient needs Client name/ Presentation Name/ 12pt - 118 © Copyright, Joint Commission International AOP.6.4 Timely Results of Reports AOP.6.5 Equipment Maintenance – – – – – – Selecting and acquiring equipment Inventorying equipment Inspecting and testing equipment Calibrating and maintaining equipment Monitoring and follow-up Adequately documenting the above requirements Client name/ Presentation Name/ 12pt - 119 © Copyright, Joint Commission International – Radiology and Diagnostic Imaging equipment management is implemented – The program includes: AOP.6.6 Available Supplies – Identified – Available – Stored and dispensed according to guidelines – Evaluated for accuracy and results – Completely and accurately labeled according Client name/ Presentation Name/ 12pt - 120 © Copyright, Joint Commission International – All x-ray film, reagents and supplies are: AOP.6.7 Qualified Director – Developing, implementing and maintaining policies and procedures – Administrative oversight – QC programs – Recommending outside sources – Monitoring and reviewing all services Client name/ Presentation Name/ 12pt - 121 © Copyright, Joint Commission International – Qualified individual(s) provide direction and oversight for all radiology and diagnostic imaging services – Responsibilities include: AOP.6.8 Quality Control – Validation of test methods – Daily surveillance of imaging results – Rapid correction when a deficiency is identified – Testing of reagents and solutions – Documentation of results and corrective actions – The program is implemented Client name/ Presentation Name/ 12pt - 122 © Copyright, Joint Commission International – The QC Program includes: AOP.6.9 Outside Services – QC results from outside sources are regularly reviewed – Qualified individuals review the QC results – A roster of experts for specialized diagnostic areas is maintained – Experts in specialized areas are contacted when needed Client name/ Presentation Name/ 12pt - 123 © Copyright, Joint Commission International AOP.6.10 Experts Client name/ Presentation Name/ 12pt - 124 © Copyright, Joint Commission International Next Presentation 125 © Copyright, Joint Commission International Care of Patients (COP) 1. Uniform Care Delivery 2. Care of High – Risk Patients and Provision of High – Risk Services 3. Food and Nutrition Therapy 4. Pain Management and End-of Life Care Client name/ Presentation Name/ 12pt - 126 © Copyright, Joint Commission International COP-Four Areas of Focus COP.1 Uniform Care Processes – Clinical and Managerial leaders provide uniform care processes – PP guide uniform care; reflect laws & regulations – – – – – Not dependent on ability to pay Needed care given independent of day of week or time Acuity of patient determines resources applies Same services delivered the same way everywhere Patients with same nursing services receive same care Client name/ Presentation Name/ 12pt - 127 © Copyright, Joint Commission International – Uniform care is provided that meets the five requirements of the intent COP.2 Integration & Coordination of Care – Care Planning and Care Delivery are integrated and coordinated among: – Results from any patient care team meetings or other collaborative discussions are written in the patient’s record Client name/ Presentation Name/ 12pt - 128 © Copyright, Joint Commission International – Settings – Departments – Services COP.2.1 Care is Planned – The care for each patient is planned by: – Plan made within 24 hrs of admission of inpatient – Planned care is individualized and based on the patient’s initial assessment data – The plan is updated or revised as needed – The care provided for each patient is written in the patient’s record by the person providing the care – The care planned is provided Client name/ Presentation Name/ 12pt - 129 © Copyright, Joint Commission International – Responsible physician – Nurse – Other healthcare professionals – Orders are written when required and are followed by organization policy – Diagnostic imaging and clinical laboratory test orders include a clinical indication/rationale when required for interpretation – Only those permitted to write orders do so – Orders are found in a uniform location in the patient records Client name/ Presentation Name/ 12pt - 130 © Copyright, Joint Commission International COP.2.2 Patient Orders – Procedures performed are written into the patient’s record including; endoscopies, cardiac catheterization and other invasive and noninvasive diagnostic and treatment procedures – The results of procedures performed are written into the patient’s record Client name/ Presentation Name/ 12pt - 131 © Copyright, Joint Commission International COP.2.3 Procedures COP.2.4 Outcomes of Care – Patients and families are informed about: Client name/ Presentation Name/ 12pt - 132 © Copyright, Joint Commission International – Outcomes of their care and treatment – Any unanticipated outcomes of their care and treatment COP.3 (and COP.3.1 – 3.9) Policy & Procedure -High-Risk Patients and Services Continued on next slide Client name/ Presentation Name/ 12pt - 133 © Copyright, Joint Commission International – Leaders identify high-risk patients and services – Develop policies and procedures – Staff are trained and use PP to guide care – The following must be reflected in PP for COP.3.1 3.9: – how planning will occur including the identification of differences between adult and pediatric populations, or other special considerations – the documentation required for the care team to work and communicate effectively – special consent considerations (if appropriate) – patient monitoring requirements – special qualifications or skills of staff involved – availability and use of specialized equipment Continued on next slide Client name/ Presentation Name/ 12pt - 134 © Copyright, Joint Commission International COP.3 (and COP.3.1 – 3.9) Policy & Procedure -High-Risk Patients and Services – COP.3.1 Care of emergency patients – COP.3.2 Resuscitation – COP.3.3 Handling, use, administration of blood and blood products – COP.3.4 Care of comatose patients – COP.3.4 Care of patients who are on life support – COP.3.5 Care of patients with communicable disease – COP.3.5 Care of immune-suppressed patients Client name/ Presentation Name/ 12pt - 135 © Copyright, Joint Commission International COP.3.1-3.9 Patients – Processes – – – – – – – COP.3.6 Care of patients on dialysis COP.3.7 Use of restraint COP.3.8 Care of frail, dependent elderly patients COP.3.8 Care of young, dependent children COP.3.8 Care of patients at risk for abuse COP.3.9 Care of patients receiving chemotherapy COP.3.9 Care of patients receiving other high-risk medications – Leaders to establish which medications are high-risk Client name/ Presentation Name/ 12pt - 136 © Copyright, Joint Commission International COP.3.1-3.9 Patients – Processes COP.4 Food Choices – Food or nutrition, appropriate to the patient, is regularly available. – All patients have an order for food in their record. – Patients have a variety of food choices consistent with their condition and care. – When families provide food, they are educated about the patient’s diet limitations. Client name/ Presentation Name/ 12pt - 137 © Copyright, Joint Commission International – The order is based on the patient’s nutritional status and needs. – Food is prepared and stored in a manner that reduces risk of contamination and spoilage. – Enteral nutrition products are stored according to manufacture recommendations and organization policy. – The distribution of food is timely, and special requests are met. – Practices meet applicable laws, regulations, and acceptable practices. Client name/ Presentation Name/ 12pt - 138 © Copyright, Joint Commission International COP.4.1 Food Preparation – Patients assessed at nutrition risk receive nutrition therapy. – A collaborative process is used to plan, deliver, and monitor nutrition therapy. – The patient’s response to nutrition therapy is monitored. – The patient’s response to nutrition therapy is recorded in his/her record. Client name/ Presentation Name/ 12pt - 139 © Copyright, Joint Commission International COP.5 Nutritional Risk Patients COP.6 Pain Management – The hospital has processes to: – Patients in pain receive care according to pain management guidelines Client name/ Presentation Name/ 12pt - 140 © Copyright, Joint Commission International – Identify patients in pain – Communicate with and educate patients and families about pain – Educate staff about pain – Staff are made aware of patients’ unique needs at the end of life. – End-of-life care includes: – providing appropriate treatment for any symptoms according to the wishes of the patient and family – sensitively addressing issues such as autopsy and organ donation – respecting the patient’s values, religion, and cultural preferences – involving the patient and family in all aspects of care – responding to the psychological, emotional, spiritual, and cultural concerns of the patient/family Client name/ Presentation Name/ 12pt - 141 © Copyright, Joint Commission International COP.7 End-of-Life Care COP.7.1 Individual Needs – Psychosocial, emotional and spiritual needs – Religious and cultural concerns – Patient and family are involved in the process Client name/ Presentation Name/ 12pt - 142 © Copyright, Joint Commission International – Interventions are taken to manage pain and other symptoms – Symptoms and complications are prevented to the extent possible – Interventions address: Client name/ Presentation Name/ 12pt - 143 © Copyright, Joint Commission International Next Presentation 144 © Copyright, Joint Commission International Anesthesia and Surgical Care (ASC) ASC-Four Areas of Focus Organization and Management Sedation Care Anesthesia Care Surgical Care Client name/ Presentation Name/ 12pt - 145 © Copyright, Joint Commission International 1. 2. 3. 4. Applicability Statement – – – – – – hospital operating theatres, day surgery or day hospital units, dental and other outpatient clinics, emergency services, intensive care areas, or elsewhere. Client name/ Presentation Name/ 12pt - 146 © Copyright, Joint Commission International – The ASC standards are applicable to what ever setting anesthesia and/or moderate or deep sedation are used and surgical and other invasive procedures that require consent are performed, including ASC.1 Anesthesia Services – Anesthesia services – meet local and national standards and laws and regs – are available to meet patient needs and are: – adequate, regular and convenient – Outside anesthesia sources are selected based on recommendations of the director and – an acceptable record of performance – compliance with applicable laws and regs Client name/ Presentation Name/ 12pt - 147 © Copyright, Joint Commission International – available for emergencies after normal hours of operation – Anesthesia services are uniform and under the direction of one or more qualified individuals – Responsibilities include – developing, implementing, and maintaining PP – administrative oversight – maintaining quality control programs – recommending outside sources of anesthesia services – include monitoring and reviewing all anesthesia services – The individuals carries out the responsibilities Client name/ Presentation Name/ 12pt - 148 © Copyright, Joint Commission International ASC.2 Qualified Director Moderate Sedation: Deep Sedation: •Patients respond purposefully to verbal commands •No interventions are needed to maintain a patent airway •Cardiovascular function is usually maintained •Patients cannot be easily aroused but respond purposefully after repeated or painful stimulation •Airway may be impaired •Cardiovascular function is usually maintained Client name/ Presentation Name/ 12pt - 149 © Copyright, Joint Commission International Sedation – Policy and procedure for moderate and deep sedation address: – How planning will occur including the identification of differences between adult and pediatric populations, or other special considerations – Documentation required for the care team to work and communicate effectively – Special consent considerations, if appropriate; – Patient monitoring requirements; – Special qualifications or skills of staff involved in sedation process – Availability and use of specialized equipment Continued on next slide Client name/ Presentation Name/ 12pt - 150 © Copyright, Joint Commission International ASC.3 Sedation ASC.3 Sedation – – – – – Techniques of various modes of sedation, Appropriate monitoring, Response to complications, Use of reversal agents, and At least basic life support. Continued on next slide Client name/ Presentation Name/ 12pt - 151 © Copyright, Joint Commission International – The qualified individual(s) identified in ASC.2 participates in the development of the Policies & Procedures – There is a pre-sedation assessment to evaluate risk and appropriateness of the sedation for the patient – The practitioner responsible for sedation is qualified in at least: – A qualified individual (other than the one performing the procedure) monitors the patient during sedation and during the period of recovery from sedation and documents the monitoring – Moderate and deep sedation are administered according to hospital policy. Client name/ Presentation Name/ 12pt - 152 © Copyright, Joint Commission International ASC.3 Sedation – A pre-anesthesia assessment is performed for each patient. – Patients are re-evaluated immediately before the induction of anesthesia. – The two assessments are performed by individual(s) qualified to do so. – The two assessments are documented in the clinical record Client name/ Presentation Name/ 12pt - 153 © Copyright, Joint Commission International ASC.4 Pre-Anesthesia Assessment ASC.5 Anesthesia Plan – The anesthesia care of each patient is planned – The plan is documented •The patient, family, and decision-makers are educated on the risks, benefits and alternatives of anesthesia •The anesthesiologist or another qualified individual provides the education Client name/ Presentation Name/ 12pt - 154 © Copyright, Joint Commission International ASC.5.1 Patient Counseling ASC.5.2 Anesthesia Technique – The anesthesia used and the anesthetic technique are written into the patient’s anesthesia record – Physiological status is continuously monitored during anesthesia administration – The results of monitoring are written into the patient’s anesthesia record Client name/ Presentation Name/ 12pt - 155 © Copyright, Joint Commission International ASC.5.3 Monitoring – Patients are monitored appropriate to their condition during the postanesthesia recovery period – Monitoring findings are entered into the patient’s record – Recovery area arrival and discharge times are recorded. Continued on next slide Client name/ Presentation Name/ 12pt - 156 © Copyright, Joint Commission International ASC.6 Post-Anesthesia ASC.6 Post-Anesthesia – By a fully qualified anesthesiologist or other individual authorized by the individual responsible for managing the anesthesia services. – By a nurse or similarly qualified individual in accordance with post-anesthesia criteria developed by the hospitals’ leaders, and is documented in the patient’s record. – The patient is discharged to a unit which has been designated as appropriate for post-anesthesia or postsedation care of selected patients, such as a Cardiovascular ICU, Neurosurgical ICU, etc. Client name/ Presentation Name/ 12pt - 157 © Copyright, Joint Commission International – Patients are discharged from the postanesthesia unit by one of 3 alternatives: ASC.7 Surgical Care – Each patient’s surgical care is planned and documented – A preoperative diagnosis is documented prior to the procedure – The planned surgical care is documented prior to the procedure Client name/ Presentation Name/ 12pt - 158 © Copyright, Joint Commission International – The planning process considers all available assessment information – The patient, family, and decision-makers are educated on the risks, benefits, potential complications and alternatives related to the planned surgical procedure. – The education includes the need for, risk and benefits of, and alternatives to blood and blood product use. – The patient’s surgeon or other qualified individual provides the education. Client name/ Presentation Name/ 12pt - 159 © Copyright, Joint Commission International ASC.7.1 Risks, Benefits, and Alternatives – Written report includes: – A postoperative diagnosis – Names of the surgeon and surgical assistants – Name of procedure – Surgical specimens sent for examination – Complications or absence of complications – Amount of blood loss – Date, time and signature of responsible physician – The written surgical report, or a brief note in the patient’s record, is available before the patient leaves the post-anesthesia recovery area. Client name/ Presentation Name/ 12pt - 160 © Copyright, Joint Commission International ASC.7.2 Surgery Report ASC.7.3 Patient Monitoring Client name/ Presentation Name/ 12pt - 161 © Copyright, Joint Commission International – The patient’s physiological status is monitored continuously during surgery – Findings are entered into the patient’s record – Each patient’s medical, nursing, and other post-surgical care is planned. – The plan(s) is documented in the patient’s record – Nursing postsurgical plan is documented – When indicated-postsurgical POC provided by others is documented – POC is documented in pt. recorded within 24 hours – Care is provided Client name/ Presentation Name/ 12pt - 162 © Copyright, Joint Commission International ASC.7.4 Post-Surgical Care Client name/ Presentation Name/ 12pt - 163 © Copyright, Joint Commission International Next Presentation 164 © Copyright, Joint Commission International Medication Management and Use (MMU) The Medication Management Processes Procurement Monitoring Storage Administration Ordering and Transcribing Preparing and Dispensing Client name/ Presentation Name/ 12pt - 165 © Copyright, Joint Commission International Selection and The Medication Use Process Order Verify Prepare Administer Monitor Client name/ Presentation Name/ 12pt - 166 © Copyright, Joint Commission International Dispense 1. 2. 3. 4. 5. 6. 7. Organization and Management Selection and Procurement Storage Ordering and Transcribing Preparing and Dispensing Administration Monitoring Client name/ Presentation Name/ 12pt - 167 © Copyright, Joint Commission International MMU-Seven Areas of Focus – There is a plan or policy or other document that identifies how medication use is organized and managed throughout the organization – All settings, services and individuals who manage medication processes are included in the organizational structure – Policies guide all phases of medication management and medication use in the organization Continue on next slide Client name/ Presentation Name/ 12pt - 168 © Copyright, Joint Commission International MMU.1 Organization & Management – There has been at least one documented review of the medication management system within the previous 12 months – The pharmacy or pharmaceutical service and medication use comply with applicable laws and regulations. – Appropriate sources of drug information are readily available to those involved in medication use. Client name/ Presentation Name/ 12pt - 169 © Copyright, Joint Commission International MMU.1 Organization & Management – An appropriately licensed, certified, and trained individual supervises all activities. – The individual provides supervision for the processes described in MMU.2 MMU.5 Standards Client name/ Presentation Name/ 12pt - 170 © Copyright, Joint Commission International MMU.1.1 Pharmacy Supervision MMU.2 Selection of Medications – (unless determined by regulation or an authority outside the organization) – There is a process established for when medications are not available that includes a notification to prescribers and suggested – substitutions Client name/ Presentation Name/ 12pt - 171 © Copyright, Joint Commission International – There is a list (formulary) of medications stocked in the hospital or readily available from outside sources. – A collaborative process was used to develop the list – There is a method for overseeing medication use in the organization – Medications are protected from loss or theft throughout the organization. – Health care practitioners involved in ordering, dispensing, administering, and monitoring processes are involved in monitoring and maintaining the medication list. Continue on next slide Client name/ Presentation Name/ 12pt - 172 © Copyright, Joint Commission International MMU.2.1 Oversight of List – Decisions to add or remove medication from the list are guided by criteria. – There is a process or mechanism to monitor patient response to medications newly added to the list. – The list is reviewed at least annually based on safety and efficacy information. Client name/ Presentation Name/ 12pt - 173 © Copyright, Joint Commission International MMU.2.1 Oversight of List MMU.2.2 Medication Availability – There is a process to – Staff understands the processes Client name/ Presentation Name/ 12pt - 174 © Copyright, Joint Commission International – approve and procure required medications not stocked or normally available to the organization. – obtain medications at times the pharmacy is closed or medication supply locked. MMU.3 Storage of Medications –Medications are stored under conditions suitable for product stability –Controlled substances are accurately accounted for according to applicable law and regulation –Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates, and warnings Continue on next slide Client name/ Presentation Name/ 12pt - 175 © Copyright, Joint Commission International – In all locations that medications are stored, the following is evident: – All medication storage areas are periodically inspected according to hospital policy to ensure medications are stored properly – Organization policy defines how medications brought in by the patient are identified and stored – Storage of concentrated electrolytes is scored at IPSG 3 Client name/ Presentation Name/ 12pt - 176 © Copyright, Joint Commission International MMU.3 Storage of Medications MMU.3.1 Special Storage – Hospital policy defines how: – All storage is according to organization policy Client name/ Presentation Name/ 12pt - 177 © Copyright, Joint Commission International – Nutrition products are stored – Radioactive, investigational and similar medications are stored – Sample medications are stored and controlled MMU.3.2 Emergency Medications – available in the units they will be needed or readily accessible to meet emergency needs – Policy defines how emergency meds are stored, maintained, and protected from loss or theft – monitored and replaced in a timely manner after use or when expired or damaged. Client name/ Presentation Name/ 12pt - 178 © Copyright, Joint Commission International – Emergency medications are MMU.3.3 Medication Recall – any use of medications known to be expired or outdated – the destruction of medications known to be expired or outdated Client name/ Presentation Name/ 12pt - 179 © Copyright, Joint Commission International – There is a medication recall system in place. – PP address MMU.4 Prescribing, Ordering and Transcribing – Policies and procedures guide: – Safe prescribing – Ordering – Transcribing related to illegible prescriptions and orders – Relevant staff is trained in correct prescribing, ordering, and transcribing practices Client name/ Presentation Name/ 12pt - 180 © Copyright, Joint Commission International – Policies and procedures address actions – Patient records contain a list of current medications taken prior to admission and this information is made available to the pharmacy and the patient’s care providers – Initial medication orders are compared to medications taken prior to admission Client name/ Presentation Name/ 12pt - 181 © Copyright, Joint Commission International MMU.4 Prescribing, Ordering and Transcribing – Acceptable medication orders or prescriptions are defined in policies: – The data necessary to accurately identify the patient – The elements of the order or prescription – When generic or brand names are acceptable or required – Whether or when indications for use are required on a PRN (as needed) or other medication order – Special precautions or procedures for ordering drugs with look-alike or sound-alike names Continue onPresentation next slide Client name/ Name/ 12pt - 182 © Copyright, Joint Commission International MMU.4.1 Medication Orders – Acceptable medication orders or prescriptions are defined in policies: – Actions to be taken when medication orders are incomplete, illegible, or unclear. – The permitted additional types of orders such as emergency, standing, automatic stop orders and any elements required in such orders – The use of verbal and telephone medication orders and the process to verify such orders – The types of orders that are weight-based such as for pediatric populations Continued on next slide Client name/ Presentation Name/ 12pt - 183 © Copyright, Joint Commission International MMU.4.1 Medication Orders MMU.4.1 Medication Orders Client name/ Presentation Name/ 12pt - 184 © Copyright, Joint Commission International – Medication orders or prescriptions are complete per organization policy. – Only those permitted by the organization and by relevant licensure, laws and regulations prescribe or order medications – There is a process to place limits, when appropriate, on the prescribing or ordering practices of individuals. – Individuals permitted to prescribe and order medications are known to the pharmaceutical service or others who dispense medications. Client name/ Presentation Name/ 12pt - 185 © Copyright, Joint Commission International MMU.4.2 Qualified Individuals MMU.4.3 Medication Documentation – Medications prescribed or ordered are recorded for each patient Client name/ Presentation Name/ 12pt - 186 © Copyright, Joint Commission International – Administration is recorded for each dose. – Information is kept in the patient’s record or inserted into his or her record at discharge or transfer – Medications are prepared and dispensed in clean and safe areas with appropriate equipment and supplies – Medications preparation and dispensing adhere to law, regulation, and professional standards of practice – Staff preparing sterile products are trained in aseptic techniques Client name/ Presentation Name/ 12pt - 187 © Copyright, Joint Commission International MMU.5 Preparing and Dispensing – The hospital defines the patient-specific information required for an effective review process – There is a process to contact the individual who prescribed or ordered the medication when questions arise – Individuals permitted to review orders or prescriptions are judged competent to do so – Review is facilitated by a record (profile) for all patients receiving medications – Computer software, when used to cross check drugs, is periodically updated Continued on next slide Client name/ Presentation Name/ 12pt - 188 © Copyright, Joint Commission International MMU.5.1 Orders are Reviewed MMU.5.1 Orders are Reviewed – the appropriateness of the drug, dose, frequency, and route of administration, – therapeutic duplication – real or potential allergies or sensitivities – real or potential interactions between the medication and other medications or food – variation from hospital criteria for use – patient’s weight & other physiological information – other contraindications Client name/ Presentation Name/ 12pt - 189 © Copyright, Joint Commission International – Each prescription or order is reviewed for appropriateness prior to dispensing – There is a uniform medication dispensing and distribution system in the organization. – Medications are appropriately labeled after preparation – Medications are dispensed in the most ready to administer form – The system supports accurate and timely dispensing Client name/ Presentation Name/ 12pt - 190 © Copyright, Joint Commission International MMU.5.2 Dispensing – The hospital identifies those individuals, by job description or the privileging process, authorized to administer medications – Only those permitted by the hospital and by relevant licensure, laws and regulations administer medications – There is a process to place limits, when appropriate, on the medication administration of individuals Client name/ Presentation Name/ 12pt - 191 © Copyright, Joint Commission International MMU.6 Individuals Qualified to Administer Medications – Medications are verified with the prescription or order – The dosage amount of the medication is verified with the prescription or order – The route of administration is verified with the prescription or order – Medications are administered on a timely basis – Medications are administered as prescribed and noted in the patient’s record Client name/ Presentation Name/ 12pt - 192 © Copyright, Joint Commission International MMU.6.1 Verification Before Administration MMU.6.2 Self Administration – Patient self-administration of medications. – The documentation and management of any medications brought into the organization for or by the patient. – The availability and use of medication samples. Client name/ Presentation Name/ 12pt - 193 © Copyright, Joint Commission International – PP are implemented to govern: – Medication effects on patients are monitored, including adverse effects – The monitoring process is collaborative – The organization has a policy that identifies those adverse effects that are to be recorded in the patient’s record and those that must be reported to the organization Continued on next slide Client name/ Presentation Name/ 12pt - 194 © Copyright, Joint Commission International MMU.7 Monitoring MMU.7 Monitoring Client name/ Presentation Name/ 12pt - 195 © Copyright, Joint Commission International – Adverse effects are documented in the patient’s record as required by policy – Adverse effects are reported in the time frame required by policy – A medication error and near-miss are defined – Medication errors and near-misses are reported in a timely manner using an established process – Those accountable for taking action on the reports are identified – The organization uses medication errors and near-misses reporting information to improve medication use processes. Client name/ Presentation Name/ 12pt - 196 © Copyright, Joint Commission International MMU.7.1 Medication Errors Client name/ Presentation Name/ 12pt - 197 © Copyright, Joint Commission International Next Presentation 198 © Copyright, Joint Commission International Patient and Family Education (PFE) – The hospital plans education consistent with its mission, services, and patient population – There is an appropriate structure or mechanism for education throughout the organization – Education resources are organized in an efficient and effective manner Client name/ Presentation Name/ 12pt - 199 © Copyright, Joint Commission International PFE.1 Patient Education PFE.2 Needs Assessed – How to participate in care decisions – Their condition and any confirmed diagnosis – Their right to participate in the care process as appropriate Client name/ Presentation Name/ 12pt - 200 © Copyright, Joint Commission International – The educational needs of the patient and family are assessed – Education needs assessment findings are recorded in the patient’s record – There is uniform recording of patient education by all staff – Patients and families learn about: PFE.2.1 Education Assessment – The patient and family are assessed on: The patient’s and family’s beliefs and values Their literacy, educational level, and language Emotional barriers and motivations Physical and cognitive limitations The patient’s willingness (formerly readiness) to receive information – The assessment findings are used to plan the education and documented in the patient’s medical record Client name/ Presentation Name/ 12pt - 201 © Copyright, Joint Commission International – – – – – – Patients and families receive education and training to meet their ongoing health needs or achieve their health goals – The organization identifies and establishes relationships with community resources that support continuing health promotion and disease prevention education – Patients are referred to these sources when appropriate and available Client name/ Presentation Name/ 12pt - 202 © Copyright, Joint Commission International PFE.3 Ongoing Health Needs PFE.4 Education Topics – The safe and effective use of all medications and potential side effects of medications – Safely and effectively using medical equipment. – Preventing interactions between prescribed medications and other medications (including non-prescription items) and food – Appropriate diet and nutrition – Pain management – Rehabilitation techniques Client name/ Presentation Name/ 12pt - 203 © Copyright, Joint Commission International – When appropriate, patients and families are educated about: – Interaction among staff, the patient, and family confirms that the information was understood – Those who provide education encourage patients and their families to ask questions and speak up as active participants – Verbal information is reinforced with written material as appropriate to the patient’s needs and learning preferences Client name/ Presentation Name/ 12pt - 204 © Copyright, Joint Commission International PFE.5 Education Methods – Patient and family education is provided collaboratively when appropriate – Those who provide education have the subject knowledge to do so – Those who provide education have adequate time to do so – Those who provide education have the communication skills to do so Client name/ Presentation Name/ 12pt - 205 © Copyright, Joint Commission International PFE.6 Collaboration Client name/ Presentation Name/ 12pt - 206 © Copyright, Joint Commission International Next Presentation 207 © Copyright, Joint Commission International Quality Improvement and Patient Safety (QPS) 1. Leadership and Planning 2. Design of New and Modified Processes 3. Data Collection for Quality Monitoring 4. Analysis of Data 5. Process Improvement 6. Proactive Risk Reduction Client name/ Presentation Name/ 12pt - 208 © Copyright, Joint Commission International QPS - Six Areas of Focus – The hospital’s leadership – participates in developing the plan for the quality improvement and patient safety (QIPS) program – participates in measuring the QIPS program – establishes the oversight process or mechanism for the hospital’s QIPS program – reports on the QIPS program to Governance Client name/ Presentation Name/ 12pt - 209 © Copyright, Joint Commission International QPS.1 Leadership – The hospital’s leaders collaborate to carry out the QIPS program – The QIPS program – is organization-wide – addresses the systems of the hospital and the role of system design and redesign in quality and safety improvement – addresses coordination among all components of the hospital’s quality monitoring and control activities – employs a systematic approach to quality improvement and patient safety Client name/ Presentation Name/ 12pt - 210 © Copyright, Joint Commission International QPS.1.1 The Program – The leaders set priorities for – measurement activities – improvement activities – patient safety activities – The priorities include the implementation of the International Patient Safety Goals Client name/ Presentation Name/ 12pt - 211 © Copyright, Joint Commission International QPS.1.2 Priorities – The leaders understand the technology and other support requirements for tracking and comparing monitoring results – The leaders provide technology and support, consistent with the hospital’s resources, for tracking and comparing monitoring results Client name/ Presentation Name/ 12pt - 212 © Copyright, Joint Commission International QPS.1.3 Support – Information on the QIPS program is communicated to staff – The communications are on a regular basis through effective channels – The communications include progress on compliance with International Patient Safety Goals Client name/ Presentation Name/ 12pt - 213 © Copyright, Joint Commission International QPS.1.4 Communication – There is a training program for staff that is consistent with their role in the QIPS program – A knowledgeable individual provides the training – Staff members participate in the training as part of their regular work assignment Client name/ Presentation Name/ 12pt - 214 © Copyright, Joint Commission International QPS.1.5 Staff Training – Quality improvement principles and tools are applied to the design of new or modified processes. – Elements of Good Process Design are considered when relevant to the process being designed or modified. – Indicators are selected to measure how well the newly designed or redesigned process operates. – Indicator data are used to evaluate the ongoing operation of the process. See next slide for Good Process Design Client name/ Presentation Name/ 12pt - 215 © Copyright, Joint Commission International QPS.2 Process Design a. Consistent with the organization’s mission and plans b. Meets the needs of patients, families, staff, and others c. Uses current practice guidelines, clinical standards, scientific literature, and other relevant evidencebased information on clinical practice design d. Consistent with sound business practices e. Considers relevant risk management information f. Builds on available knowledge and skills in the organization g. Builds on the best/better/good practices of other organizations h. Uses information from related improvement activities i. Integrates and connects processes and systems Client name/ Presentation Name/ 12pt - 216 © Copyright, Joint Commission International Good Process Design – Hospital and clinical leaders use – clinical guidelines to guide patient care processes – clinical pathways to standardize care processes – The process is used to adapt, adopt or update at least one guideline and one pathway per 12 month period See next page for CPG Process Client name/ Presentation Name/ 12pt - 217 © Copyright, Joint Commission International QPS.2.1 Clinical Guidelines and Pathways a. Selected from among those applicable to the services and patients of the hospital – Mandatory national guidelines, if any, are implemented b. Evaluated for their applicability and science c. Adapted when needed to the technology, drugs and other resources of the organization or to accepted national professional norms d. Formally approved or adopted by the hospital e. Implemented and monitored for consistent use and effectiveness f. Supported by staff trained to apply the guidelines or pathways Client name/ Presentation Name/ 12pt - 218 g. Periodically updated © Copyright, Joint Commission International Implementing Clinical Guidelines and Pathways – The leaders identify targeted areas for measurement and improvement – Measurement is part of quality improvement and patient safety program – Measurement results communicated to: – Oversight mechanism – Organizational leaders – Governance structure Client name/ Presentation Name/ 12pt - 219 © Copyright, Joint Commission International QPS.3 Key Measures – – – – – – – – – – Patient assessments Laboratory services Radiology and diagnostic imaging services Surgical procedures Antibiotic and other medication use Anesthesia and sedation use Use of blood and blood products Patient record Infection, prevention and control Clinical research Client name/ Presentation Name/ 12pt - 220 © Copyright, Joint Commission International QPS.3.1 Clinical Measurement – Leaders identify key measures for each clinical area – At least 5 of the 11 measures are selected from JCI Library of Measures – Leaders look at the science and evidence Continued on next slide Client name/ Presentation Name/ 12pt - 221 © Copyright, Joint Commission International QPS.3.1 Clinical Measures – Measurement includes structure, processes and outcomes – Scope, method and frequency are identified for each measure – Clinical measurement data are collected and used to evaluate the effectiveness of improvements Client name/ Presentation Name/ 12pt - 222 © Copyright, Joint Commission International QPS.3.1 Clinical Measures – Procurement of routinely required supplies and medications – Reporting of activities as required by law and regulations – Risk management – Utilization management – Patient and family expectations and satisfaction – Staff expectations and satisfaction – Patient demographics and clinical diagnosis – Financial management – Prevention and control of events that jeopardize the safety of patients, families and staff Client name/ Presentation Name/ 12pt - 223 © Copyright, Joint Commission International QPS.3.2 Managerial Measures – Managerial leaders identify measures for managerial areas – Leaders look at the science or evidence – Measurement includes structure, processes and outcomes – Scope, method and frequency are identified for each measure – Data are collected and used to evaluate effectiveness of improvements Client name/ Presentation Name/ 12pt - 224 © Copyright, Joint Commission International QPS.3.2 Managerial Measures QPS.3.3 Measures for IPSG Client name/ Presentation Name/ 12pt - 225 © Copyright, Joint Commission International – Clinical and managerial leaders identify key measures for IPSG – Measurement data are used to evaluate effectiveness of improvement – Data are aggregated, analyzed, and transformed into useful information – Individuals with appropriate clinical or managerial experience, knowledge, and skills participate in the process – Statistical tools and techniques are used in the analysis process when appropriate – Results are reported to those accountable for taking action Client name/ Presentation Name/ 12pt - 226 © Copyright, Joint Commission International QPS.4 Analysis of Data QPS.4.1 Frequency of Data Analysis – The frequency of data analysis: – is appropriate to the process under study – meets organization requirements – Comparisons are made: – Over time within the organization – With similar organizations when possible – With standards when appropriate – With known desirable practices Client name/ Presentation Name/ 12pt - 227 © Copyright, Joint Commission International QPS.4.2 Data Comparisons QPS.5 Data Validation Continued on next slide Client name/ Presentation Name/ 12pt - 228 © Copyright, Joint Commission International – Hospital integrates data validation into the quality management and improvement program – Data validation includes the measures selected as required in QPS.3.1 – Internal validation includes: – Re-collecting data by a second person – Using statistically valid sample of records, cases and data – Comparing original data with re-collected data – Calculating accuracy – Noting unclear data and taking corrective actions – Collecting new samples after corrective answers Client name/ Presentation Name/ 12pt - 229 © Copyright, Joint Commission International QPS.5 Data Validation QPS.5.1 Published Data Client name/ Presentation Name/ 12pt - 230 © Copyright, Joint Commission International – Leaders assume accountability for reliability of quality and outcome data – Data made public have been evaluated for reliability and validity – Establish a definition of a sentinel event: – Unanticipated death unrelated to the course of illness – Major permanent loss of function unrelated to natural course of illness – Wrong site, wrong procedure, wrong patient – Infant abduction or infant sent home with wrong parents Continued on next slide Client name/ Presentation Name/ 12pt - 231 © Copyright, Joint Commission International QPS.6 Sentinel Events – Conducts a Root Cause Analysis on all sentinel events from previous slide – Events are analyzed as they occur – Leaders take action on results of Root Cause Analysis Client name/ Presentation Name/ 12pt - 232 © Copyright, Joint Commission International QPS.6 Sentinel Events QPD.7 Undesirable Trends – – – – Transfusion reactions Drug events Medication errors Major discrepancies in pre-op and post-op diagnosis – Moderate or deep sedation and anesthesia – Other events defined by hospital Client name/ Presentation Name/ 12pt - 233 © Copyright, Joint Commission International – Intense analysis take place when adverse levels, patterns and trends occur – The hospital establishes a definition of a near-miss – Defines the type of events to be reported – The hospital establishes the process for the reporting of near- misses – The data are analyzed and actions taken to reduce near-miss events Client name/ Presentation Name/ 12pt - 234 © Copyright, Joint Commission International QPS.8 Near Misses Definitions Actual SE Examples Response JCI can review RCA Add to SE Database SE Policy Patient death from medication misadministration "reviewable" On-going data collection Significant misadministration -- patient survives Adverse events "Important single events" Full range of events, incidents, occurrences, etc. Majority of medication errors Client name/ Presentation Name/ 12pt - 235 © Copyright, Joint Commission International Conduct RCA Not subject to SE definition Evaluate process at triennial survey – Plan and implement improvements in quality and safety – Consistently identify priority improvements selected by leaders – Document improvements achieved and sustained Client name/ Presentation Name/ 12pt - 236 © Copyright, Joint Commission International QPS.9 Improvement Activities – Leaders identify priority areas – Human or other resources are allocated or assigned – Changes are planned and tested – Changes are implemented – Data demonstrates effective and sustained improvements – Successful improvements are documented Client name/ Presentation Name/ 12pt - 237 © Copyright, Joint Commission International QPS.10 Priority Areas QPS.11 Identify and Reduce Unanticipated Adverse Events – Leaders adopt a framework that: – Conducts and documents a pro-active risk reduction annually – Take action to redesign high-risk processes based on analysis Client name/ Presentation Name/ 12pt - 238 © Copyright, Joint Commission International – Risk identification, prioritization, reporting, management – Investigation of adverse events – Management of related claims Client name/ Presentation Name/ 12pt - 239 © Copyright, Joint Commission International Next Presentation 240 © Copyright, Joint Commission International Prevention and Control of Infections (PCI) PCI - Six Areas of Focus Program Leadership and Coordination Focus of the Program Isolation Procedures Barrier Techniques and Hand Hygiene Integration of Program with Quality Improvement and Patient Safety 6. Education of Staff About the Program Client name/ Presentation Name/ 12pt - 241 © Copyright, Joint Commission International 1. 2. 3. 4. 5. – One or more individuals oversee the infection control program – The individual(s) is/are qualified for the organization’s size, level of risks, and program scope and complexity – The individual(s) fulfills program oversight responsibilities as assigned or described in a job description Client name/ Presentation Name/ 12pt - 242 © Copyright, Joint Commission International PCI.1 Oversight of Program – There is a designated mechanism for the coordination of the infection control program – Coordination of infection control activities involves: – Medicine – Nursing – Infection control professionals – Housekeeping – Others (as appropriate) – (Note that a Committee is not required but most hospitals find coordination easiest if there is one) Client name/ Presentation Name/ 12pt - 243 © Copyright, Joint Commission International PCI.2 Coordination of Activities – The infection control program is based on: – Current scientific knowledge – Accepted practice guidelines – Applicable law and regulation – National standards or local agencies –For sanitation and cleanliness Client name/ Presentation Name/ 12pt - 244 © Copyright, Joint Commission International PCI.3 Infection Control Program – The infection control program is adequately staffed as approved by the leadership – The organization’s leaders allocate adequate resources for the infection control program – Information management systems support the infection control program (an area highlighted as needing special IT attention) Client name/ Presentation Name/ 12pt - 245 © Copyright, Joint Commission International PCI.4 Adequate Resources – There is a comprehensive program and plan to reduce the risk of health care-associated infections – in patients – in health care workers – The program – includes systematic and proactive surveillance activities to determine usual (endemic) rates of infection. – includes systems to investigate outbreaks of infectious diseases – is guided by appropriate PP Continued on next slide Client name/ Presentation Name/ 12pt - 246 © Copyright, Joint Commission International PCI.5 Comprehensive Program – Risk reduction goals and measurable objectives are established and regularly reviewed – The program is appropriate to the hospital’s size and geographic location, services, and patients Client name/ Presentation Name/ 12pt - 247 © Copyright, Joint Commission International PCI.5 Comprehensive Program – All patient care areas of the hospital are included in the infection control program – All staff areas of the hospital are included in the infection control program – All visitor areas of the hospital are included in the infection control program Client name/ Presentation Name/ 12pt - 248 © Copyright, Joint Commission International PCI.5.1 Areas Included – The organization uses a risk based approach in establishing the focus of the health care associated infection prevention and reduction program. – Data evaluation/analysis actions are taken to focus or refocus infection prevention and control program – Assess annually and document the assessment. Continued next slide Client name/ Presentation Name/ 12pt - 249 © Copyright, Joint Commission International PCI.6 Focus of Program – Organizations collect and evaluate data on the following relevant infections and sites: – Respiratory tract infections – Urinary tract infections – Intravascular invasive devices – Surgical wounds – Epidemiologically significant diseases and organisms in the hospital & community – Emerging or reemerging infections in the hospital & community Client name/ Presentation Name/ 12pt - 250 © Copyright, Joint Commission International PCI.6 Focus of Program – The hospital has identified those processes associated with infection risk – The hospital has implemented strategies to reduce infection risk in those processes – The hospital identifies which risks require policies and or procedures, staff education, practice changes and other activities to support risk reduction Client name/ Presentation Name/ 12pt - 251 © Copyright, Joint Commission International PCI.7 Risk Processes – Equipment cleaning and sterilization methods in and outside of the central sterilization service are appropriate for the type of equipment – Laundry and linen management are appropriate to minimize risk to staff and patients – There is a coordinated oversight process for all cleaning, disinfection and sterilization throughout the hospital Continued next slide Client name/ Presentation Name/ 12pt - 252 © Copyright, Joint Commission International PCI.7.1 Equipment/Laundry/Sterilization – Managing expired supplies and reuse of single use devices – Policy and procedure consistent with national laws, regulations, and professional standards for expired supplies – When can single use devices be reused – Implement and monitor the policy Client name/ Presentation Name/ 12pt - 253 © Copyright, Joint Commission International PCI.7.1.1 Equipment/Laundry/Sterilization – Managing to minimize transmission risk of: – Disposal of infectious waste and body fluids – Handling and disposal of blood and blood components (including blood samples) – Operation of the mortuary and postmortem area Client name/ Presentation Name/ 12pt - 254 © Copyright, Joint Commission International PCI.7.2 Waste Disposal – Sharps and needles are collected in dedicated, puncture-proof containers which are not re-used (and not overfilled) – The hospital disposes of sharps and needles safely or contracts with sources that ensure the sharps containers are disposed of in dedicated hazardous waste sites or by an appropriate process – The disposal of sharps and needles is consistent with infection control policies of the hospital Client name/ Presentation Name/ 12pt - 255 © Copyright, Joint Commission International PCI.7.3 Sharps and Needles – Kitchen sanitation and food preparation and handling are appropriate to minimize infection risk – Engineering controls are implemented as appropriate to minimize infection risk in appropriate areas of the organization Client name/ Presentation Name/ 12pt - 256 © Copyright, Joint Commission International PCI.7.4 Food Service & Engineering PCI.7.5 Construction & Renovation Client name/ Presentation Name/ 12pt - 257 © Copyright, Joint Commission International – The hospital uses risk criteria to assess the impact of renovation or new construction – The risks and impact of the renovation or construction on air quality and infection control activities is assessed and managed – Patients with known contagious diseases are isolated in accordance with hospital policy and recommended guidelines – PP address the separation of patients with communicable diseases from patients and staff who are at greater risk due to immunosuppression or other reasons Continued next slide Client name/ Presentation Name/ 12pt - 258 © Copyright, Joint Commission International PCI.8 Barrier Precautions – The hospital has a strategy of dealing with an influx of patients with contagious diseases – Appropriate negative pressure rooms are available and monitored routinely for infectious patients that require isolation – Staff is educated in the management of infectious patients Client name/ Presentation Name/ 12pt - 259 © Copyright, Joint Commission International PCI.8 Barrier Precautions – The hospital identifies those situations for which gloves and/or masks or eye protection are required – Gloves and/or masks or eye protection are correctly used in those situations – The hospital identifies those areas where hand washing and hand disinfection or surface disinfecting procedures are required – Hand washing and hand disinfection procedures are used correctly in those areas – The hospital has adopted hand hygiene guidelines from an authoritative source Client name/ Presentation Name/ 12pt - 260 © Copyright, Joint Commission International PCI.9 Gloves, Masks, Eye Protection – Infection control activities are integrated into the hospital’s quality improvement and patient safety program – The leadership of the infection control program is included in the hospital’s quality and patient safety program’s oversight mechanism Client name/ Presentation Name/ 12pt - 261 © Copyright, Joint Commission International PCI.10 Quality Integration – Health care-associated infection risks are tracked – Health care-associated infection rates are tracked – Health care-associated infection trends are tracked Client name/ Presentation Name/ 12pt - 262 © Copyright, Joint Commission International PCI.10.1 Risks, Rates, & Trends PCI.10.2 Important Measures Client name/ Presentation Name/ 12pt - 263 © Copyright, Joint Commission International – Infection prevention and control activities are measured – The measures identify epidemiologically important infections – Processes are redesigned based on risk, rate, and trend data and information – Processes are redesigned to reduce infection risk to the lowest levels possible Client name/ Presentation Name/ 12pt - 264 © Copyright, Joint Commission International PCI.10.3 Process Redesign PCI.10.4 Comparisons Client name/ Presentation Name/ 12pt - 265 © Copyright, Joint Commission International – Health care-associated infection rates are compared to other organizations’ rates through comparative databases – The organization compares its rates to best practices and scientific evidence PCI.10.5 Communication of Monitoring Results – medical staff – nursing staff – management Client name/ Presentation Name/ 12pt - 266 © Copyright, Joint Commission International – Monitoring results are communicated to the following: PCI.10.6 Reporting to Outside Agencies Client name/ Presentation Name/ 12pt - 267 © Copyright, Joint Commission International – The organization takes appropriate action on reports from relevant public health agencies – Infection control program results are reported to public health agencies as required – The organization provides education about infection control – Clinical staff and other professional staff are included in the program – Patients and families are included when appropriate to the patient’s needs and condition Continued on next slide Client name/ Presentation Name/ 12pt - 268 © Copyright, Joint Commission International PCI.11 Education – All staff is oriented to the policies, procedures, and practices of the infection control program – Periodic staff education includes new policies and procedures – Periodic staff education is in response to significant trends in infection data – Patients and families are encouraged to participate in the infection control program Client name/ Presentation Name/ 12pt - 269 © Copyright, Joint Commission International PCI.11 Education Client name/ Presentation Name/ 12pt - 270 © Copyright, Joint Commission International Next Presentation 271 © Copyright, Joint Commission International Governance, Leadership, and Direction (GLD) 1. Governance of the Organization 2. Leadership of the Organization 3. Direction of Departments and Services 4. Organizational Ethics Client name/ Presentation Name/ 12pt - 272 © Copyright, Joint Commission International GLD - Four Areas of Focus – The organization’s governance structure is described in written documents – Governance responsibilities and accountabilities are described in the documents – The documents describe how the performance of the governing entity and managers will be evaluated and any related criteria – There has been one documented performance evaluation of governance Client name/ Presentation Name/ 12pt - 273 © Copyright, Joint Commission International GLD.1 Governance – Those responsible for governance – approve the organization’s mission – ensure the periodic review of the organization’s mission – make public the organization’s mission Client name/ Presentation Name/ 12pt - 274 © Copyright, Joint Commission International GLD.1.1 Mission – Those responsible for governance approve the organization’s: – Strategic and management plans – Operating policies and procedures – When approval authority is delegated it is defined in governance polices and procedures – Those responsible for governance approve organization strategies and programs related to health care professional education and research and then provide oversight of the quality of such programs Client name/ Presentation Name/ 12pt - 275 © Copyright, Joint Commission International GLD.1.2 Operational Responsibilities – Those responsible for governance – approve the organization’s capital and operating budgets – allocate the resources required to meet the organization’s mission Client name/ Presentation Name/ 12pt - 276 © Copyright, Joint Commission International GLD.1.3 Budget – Those responsible for governance – appoint the organization’s senior manager – evaluate the performance of the organization’s senior manager annually Client name/ Presentation Name/ 12pt - 277 © Copyright, Joint Commission International GLD.1.4 Appoint Senior Management and Directors GLD.1.5 Reports of Quality and Patient Safety Client name/ Presentation Name/ 12pt - 278 © Copyright, Joint Commission International – Approval of the organizational plan for quality and patient safety – Receive and act on reports of the quality and patient safety program GLD.2 Senior Leader – Manages the organization’s day-to-day operations – Has the education and experience to carry out his or her responsibilities – Recommends policies to the governing body – Ensures compliance with approved policies – Ensures compliance with applicable law and regulation – Responds to any reports from inspecting and regulatory agencies Client name/ Presentation Name/ 12pt - 279 © Copyright, Joint Commission International – The senior manager or director: – The leaders of the hospital are formally or informally identified – The leaders are collectively responsible – for defining the hospital’s mission – creating the PP necessary to carry out the mission – The leaders work collaboratively to carry out the organization’s mission and ensure that PP are followed Client name/ Presentation Name/ 12pt - 280 © Copyright, Joint Commission International GLD.3 Hospital Leaders – The hospital’s leaders – plan with recognized community leaders – plan with the leaders of other provider organizations in its community – seek the input of individual and group stakeholders in its community as part of its strategic and operational planning – The organization participates in community education on health promotion and disease prevention Client name/ Presentation Name/ 12pt - 281 © Copyright, Joint Commission International GLD.3.1 Leadership Planning – Organization plans describe the care and services to be provided – The care and services to be offered are consistent with the organization’s mission – Clinical leaders – determine the type of care and services to be provided by the organization – have a process for reviewing and approving, before use in patient care, those procedures, technology and pharmaceutical agents considered experimental Client name/ Presentation Name/ 12pt - 282 © Copyright, Joint Commission International GLD.3.2 Clinical Leaders – The organization identifies recommendations of professional organizations and other authoritative sources in relation to the equipment and supplies needed to provide services – Recommended equipment, supplies and medications are – obtained as appropriate – Used as appropriate Client name/ Presentation Name/ 12pt - 283 © Copyright, Joint Commission International GLD.3.2.1 Equipment and Supplies – There is a process for leadership oversight of contracts – There is a written description of services provided by contractual agreements – Services provided under contracts and other arrangements meet patient needs – Clinical and managerial leaders participate in selection of clinical contracts and are accountable – Patient services are maintained when contracts are negotiated and terminated Client name/ Presentation Name/ 12pt - 284 © Copyright, Joint Commission International GLD.3.3 Contracts – Contracts and other arrangements are evaluated as part of the quality and patient safety program – Clinical and manager leaders participate – Action is taken when contracted services do not meet quality and patient safety expectations Client name/ Presentation Name/ 12pt - 285 © Copyright, Joint Commission International GLD.3.3.1 Contracts and Quality Improvement – Leaders determine services provided by independent practitioners (IP) outside the organization – Diagnostic, consultative, and other treatment services provided by IP are privileged – IP not employed or members of the clinical staff are credentialed and privileged – Quality of services by IP is monitored Client name/ Presentation Name/ 12pt - 286 © Copyright, Joint Commission International GLD.3.3.2 Independent Practitioners – Medical, nursing, and other clinical leaders: – Are educated in or are familiar with the concepts and methods of quality improvement – Participate in relevant quality improvement and patient safety processes – Professional performance is monitored as part of clinical monitoring Client name/ Presentation Name/ 12pt - 287 © Copyright, Joint Commission International GLD.3.4 QI Concepts – There is a planned process for staff recruitment and retention – There is a planned process for staff personal development and continuing education – The planning is collaborative and includes all departments and services in the organization Client name/ Presentation Name/ 12pt - 288 © Copyright, Joint Commission International GLD.3.5 Recruitment and Retention – There is an (are) effective organizational structure(s) used by medical, nursing, and other clinical leaders to carry out their responsibilities and authority – The structure(s) is (are) appropriate to the organization’s size and complexity – The organizational structure(s) and processes – support professional communication – support clinical planning and policy development – support oversight of professional ethical issues – support oversight of the quality of clinical services Client name/ Presentation Name/ 12pt - 289 © Copyright, Joint Commission International GLD.4 Structures – An individual with appropriate training, education, and experience directs each department or service in the organization – When more than one individual provides direction, the responsibilities of each are defined in writing Client name/ Presentation Name/ 12pt - 290 © Copyright, Joint Commission International GLD.5 Department Directors – Department or service directors have selected and use a uniform format and content for planning documents – Departmental or service documents describe the current and planned services provided by each department or service – Each department’s or service’s PP – guide the provision of identified services – address the staff knowledge and skills needed to assess and meet patient needs Client name/ Presentation Name/ 12pt - 291 © Copyright, Joint Commission International GLD.5.1 Departments/Services – There is coordination and integration of services within each department or service – There is coordination and integration of services with other departments and services Client name/ Presentation Name/ 12pt - 292 © Copyright, Joint Commission International GLD.5.1.1 Coordination & Integration – Department and service directors recommend – space needed to provide services – equipment needed to provide services – the number and qualifications of staff needed to provide services – other special resources needed to provide services – Department and service directors have a process to respond to resource shortages Client name/ Presentation Name/ 12pt - 293 © Copyright, Joint Commission International GLD.5.2 Directors’ Role – The director develops criteria related to the needed education, skills, knowledge and experience of the department’s professional staff – The director uses such criteria in selecting or recommending professional staff Client name/ Presentation Name/ 12pt - 294 © Copyright, Joint Commission International Gld.5.3 Staff Selection Criteria GLD.5.4 Orientation Client name/ Presentation Name/ 12pt - 295 © Copyright, Joint Commission International – The director has established an orientation program for department staff – All department staff has completed the program – Directors implement quality monitors that address the services provided in their department or service using the following criteria: – The organization’s monitoring and improvement priorities that relate to the department or service – The evaluation of the provided services, from sources including patient surveys and complaints – The need to understand the efficiency and cost effectiveness of the services provided – Contractual arrangements – Quality control programs when indicated Continued onPresentation next slide Client name/ Name/ 12pt - 296 © Copyright, Joint Commission International GLD.5.5 Departmental Monitors – Department or service directors are provided the data and information needed to manage and improve care and services – Department and service quality monitoring and improvement activities are reported periodically to the quality oversight mechanism of the organization Client name/ Presentation Name/ 12pt - 297 © Copyright, Joint Commission International GLD.5.5 Departmental Monitors – Organization leaders establish ethical and legal norms that protect patients and their rights – The leaders establish a framework for the organization’s ethical management – Leaders consider national and international ethical norms when developing ethical framework Continued on next slide Client name/ Presentation Name/ 12pt - 298 © Copyright, Joint Commission International GLD.6 Ethical Management – International documents intended to shape ethical norms: – Universal Declaration of Human Rights – Geneva Conventions – Declaration of Tokyo: Guidelines for Physicians Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment – Oath of Athens – International Covenant on Civil and Political Rights – Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment of Punishment Client name/ Presentation Name/ 12pt - 299 © Copyright, Joint Commission International GLD.6 Ethical Management – The organization – discloses its ownership. – honestly portrays its services to patients – provides clear admission, transfer, and discharge policies – accurately bills for services – discloses and resolves conflicts when financial incentives and payment arrangements compromise patient care Client name/ Presentation Name/ 12pt - 300 © Copyright, Joint Commission International GLD.6.1 Ethical Framework – The organization’s framework for ethical management supports those confronted by ethical dilemmas in patient care and non-clinical services – The support is readily available – Allows for safe reporting of ethical and legal concerns Client name/ Presentation Name/ 12pt - 301 © Copyright, Joint Commission International GLD.6.2 Support for Ethical Dilemmas Client name/ Presentation Name/ 12pt - 302 © Copyright, Joint Commission International Next Presentation 303 © Copyright, Joint Commission International Facility Management (FMS) 1. 2. 3. 4. 5. 6. 7. Leadership and Planning Safety and Security Hazardous Materials Disaster Preparedness Medical Equipment Utility Systems Staff Education Client name/ Presentation Name/ 12pt - 304 © Copyright, Joint Commission International FMS - Eight Areas of Focus – The hospital’s leaders – know what laws, regulations, and other requirements apply to the hospital’s facilities – implement the applicable requirements or approved alternatives – ensure that the hospital meets the conditions of facility inspection reports or citations Client name/ Presentation Name/ 12pt - 305 © Copyright, Joint Commission International FMS.1 Laws and Regulations There are written plans that address the risk areas for: – Safety and Security – Safety - The degree to which the organization’s buildings, grounds and equipment do not pose a hazard or risk to patients, staff, visitors – Security – Protection from loss, destruction, tampering, or unauthorized access or use Continued on next slide Client name/ Presentation Name/ 12pt - 306 © Copyright, Joint Commission International FMS.2 Plans – Other required plans – Hazardous Materials– Handling, storage, and use of radioactive and other materials are controlled, and hazardous waste is safely disposed – Emergencies – Response to epidemics, disasters, and emergencies is planned and effective – Fire safety – Property and occupants are protected from fire and smoke – Medical equipment – Equipment is selected, maintained, and used in a manner to reduce risks – Utility systems – Electrical, water, and other utility systems are maintained to minimize the risks of operating failures Continued on next slide Client name/ Presentation Name/ 12pt - 307 © Copyright, Joint Commission International FMS.2 Plans – The plans are current or up-to-date – Current means no older a year (see below) – The plans are – fully implemented – reviewed and updated at least on an annual basis – (having six separate plans is not required. There may be a fewer number of documents as long as they cover the respective areas adequately, in accordance with Standards) Client name/ Presentation Name/ 12pt - 308 © Copyright, Joint Commission International FMS.2 Plans – Program oversight and direction are assigned to one or more individuals, qualified by experience or training – The individual(s) plans and implements the program including: a) planning all aspects of the program b) implementing the program c) educating staff d) testing and monitoring the program e) periodically reviewing and revising the program f) annual reports to the governing body on the effectiveness of the program g) providing consistent and continuous organization and management Continued on next slide Client name/ Presentation Name/ 12pt - 309 © Copyright, Joint Commission International FMS.3 Program Oversight FMS.3.1 Monitoring Program Client name/ Presentation Name/ 12pt - 310 © Copyright, Joint Commission International – There is a program to monitor all aspects of the facility/environment risk management program – Monitoring data are used to improve the program – The hospital has a program to provide a safe and secure physical facility – The program – ensures that all staff, visitors and vendors are identified and all security risk areas are monitored and kept secure – is effective in preventing injury and maintaining safe conditions for patients, families, staff, and visitors – includes safety and security during times of construction and renovation – The leaders apply resources in accordance with approved plans Client name/ Presentation Name/ 12pt - 311 © Copyright, Joint Commission International FMS.4 Safe and Secure – The hospital has a documented, current, accurate inspection of its physical facilities – (Current means less than a year old) – The hospital has a plan to reduce evident risks based on the inspection – (“Evident risks” are those cited in the inspection report) – The hospital is making progress in carrying out the plan Client name/ Presentation Name/ 12pt - 312 © Copyright, Joint Commission International FMS.4.1 Facility Inspection – The hospital plans and budgets – to meet applicable laws, regulations, and other requirements – for upgrading or replacing systems, buildings, or components needed for the continued operation of a safe and effective facility Client name/ Presentation Name/ 12pt - 313 © Copyright, Joint Commission International FMS.4.2 Budgeting – The hospital identifies hazardous materials and waste and has a current list of all such materials within the organization – Includes at least chemicals, Chemotherapy agents, radioactive materials and waste, hazardous gases and vapors, and other regulated medical and infectious waste (see Intent Statement) – The plan identifies documentation requirements including any permits, licenses, or other regulatory requirements Continued on next slide Client name/ Presentation Name/ 12pt - 314 © Copyright, Joint Commission International FMS.5 Hazardous Materials – The plan includes – safe handling, storage, and use – reporting and investigation of spills, exposures, and other incidents – the proper handling of waste within the hospital and disposal of hazardous waste in a safe and legal manor – the proper protective equipment and procedures during use, spill, or exposure – labeling hazardous materials and waste Client name/ Presentation Name/ 12pt - 315 © Copyright, Joint Commission International FMS.5 Hazardous Materials – The hospital has identified the major internal and external disasters and major epidemic events which pose significant risks of occurring – The hospital plans its response to likely disasters including determining the type, likelihood and consequences of events Continued on next slide Client name/ Presentation Name/ 12pt - 316 © Copyright, Joint Commission International FMS.6 Disaster Preparedness – The Emergency Management Plan also includes: –the hospital’s role –communication strategies –the managing of resources including alternative sources –the managing of clinical activities including alternative care sites –the identification and assignment of staff roles and responsibilities Client name/ Presentation Name/ 12pt - 317 © Copyright, Joint Commission International FMS.6 Disaster Preparedness FMS.6.1 Testing the Emergency Plan Client name/ Presentation Name/ 12pt - 318 © Copyright, Joint Commission International – The Emergency Plan is tested annually – A debriefing occurs after the test – Any independent entities within patient care facilities comply with the plan – The hospital plans a program to ensure that all occupants of its facilities are safe from fire, smoke, or other non-fire emergencies – (“Internal Disasters”) – The program is implemented in a continuous and comprehensive manner to ensure that all patient care and staff work areas are included – Any independent entities within patient care facilities comply with the plan Client name/ Presentation Name/ 12pt - 319 © Copyright, Joint Commission International FMS.7 Fire Safety – The program includes: – the reduction of fire risks – the early detection of fire and smoke – the abatement of fire and containment of smoke – the safe exit from the facility when fire and non-fire emergencies occur – the assessment of fire risks when construction is present in or adjacent to the facility Client name/ Presentation Name/ 12pt - 320 © Copyright, Joint Commission International FMS.7.1 Fire Safety Program – Fire detection and abatement systems are inspected, tested, and maintained at a frequency determined by the organization – The fire and smoke safety evacuation plan is tested at least twice a year – Staff is trained to participate in the fire and smoke safety plan – Staff participates in at least one fire and smoke safety test per year – Inspection, testing, and maintenance of equipment and systems are documented Client name/ Presentation Name/ 12pt - 321 © Copyright, Joint Commission International FMS.7.2 Testing Fire Plan – The hospital has developed and implemented a policy and plan to eliminate or limit smoking – Eliminates it altogether, or limits it to specified non-clinical areas, vented to outside (See Intent Statement) – The plan applies to patients, families, visitors, and staff – There is a process to grant patient exceptions to the plan – (e.g. psychiatric patients, selected others) Client name/ Presentation Name/ 12pt - 322 © Copyright, Joint Commission International FMS.7.3 Smoking – Medical equipment is managed throughout the hospital according to a plan – There is an inventory of all medical equipment – Medical equipment is regularly inspected – Medical equipment is tested when new and as appropriate thereafter – (Testing for safety) – There is a preventive maintenance program – Qualified individuals provide these services Client name/ Presentation Name/ 12pt - 323 © Copyright, Joint Commission International FMS.8 Medical Equipment – Monitoring data are collected and documented for the medical equipment management program – Monitoring data are used for purposes of planning and improvement Client name/ Presentation Name/ 12pt - 324 © Copyright, Joint Commission International FMS.8.1 Monitoring of Equipment – There is a product/equipment recall system in place – Policy or procedure addresses any use of any product or equipment under recall – The policy or procedure is implemented Client name/ Presentation Name/ 12pt - 325 © Copyright, Joint Commission International FMS.8.2 Recall System FMS.9 Drinking Water and Electrical Power Client name/ Presentation Name/ 12pt - 326 © Copyright, Joint Commission International – Potable water is available 24 hours a day, seven days a week – Electrical power is available 24 hours a day, seven days a week FMS.9.1 Backup for Failure FMS.9.2 Testing of Supply The hospital regularly tests alternate sources of water and electricity annually - documents the results of such tests - Client name/ Presentation Name/ 12pt - 327 © Copyright, Joint Commission International – The hospital – has identified the areas and services at greatest risk when power fails or water is contaminated or interrupted – seeks to reduce the risks of such events – plans alternate sources of power and water in emergencies – Utility, medical gas, ventilation and other key systems are identified by the organization – Key systems are: – Regularly inspected – Regularly tested – Regularly maintained – Improved when necessary Client name/ Presentation Name/ 12pt - 328 © Copyright, Joint Commission International FMS.10 Testing of Systems – Water quality is monitored regularly – Chemical and biological – Interval to be determined – Water used in chronic renal dialysis is tested regularly – Chemical and biological – Interval to be determined Client name/ Presentation Name/ 12pt - 329 © Copyright, Joint Commission International FMS.10.1 Water Testing – Monitoring data are – collected and documented for the medical utility management program – used for purposes of planning and improvement Client name/ Presentation Name/ 12pt - 330 © Copyright, Joint Commission International FMS.10.2 Monitoring Data – For each component of the organization’s facility management and safety program, there is planned education to ensure that staff members can effectively carry out their responsibilities – The education includes visitors, vendors, contract workers, and others as appropriate to the organization and multiple shifts of staff – What kind of education for each group? Client name/ Presentation Name/ 12pt - 331 © Copyright, Joint Commission International FMS.11 Education for Staff and Others – Staff members can describe and/or demonstrate – their role in response to a fire – actions to eliminate, minimize, or report safety, security, and other risks – precautions, procedures, and participation in the storage, handling, and disposal of medical gases, hazardous waste and materials and in related emergencies – procedures and their role in internal and community emergencies and disasters Client name/ Presentation Name/ 12pt - 332 © Copyright, Joint Commission International FMS.11.1 Staff Knowledge FMS.11.2 Medical Equipment Training Client name/ Presentation Name/ 12pt - 333 © Copyright, Joint Commission International – Staff is trained to operate and maintain medical equipment appropriate to their job requirements – Staff knowledge is tested regarding their role in maintaining a safe and effective facility – Staff training and testing are documented as to who was trained and tested and the results Client name/ Presentation Name/ 12pt - 334 © Copyright, Joint Commission International FMS.11.3 Testing Staff Knowledge Client name/ Presentation Name/ 12pt - 335 © Copyright, Joint Commission International Next Presentation 336 © Copyright, Joint Commission International Staff Qualifications and Education (SQE) 1. 2. 3. 4. 5. Planning Orientation and Education Medical Staff Nursing Staff Other Professional Staff Client name/ Presentation Name/ 12pt - 337 © Copyright, Joint Commission International SQE - Six Areas of Focus – The organization’s mission, mix of patients, services, and technology are considered in planning – The desired education, skills, and knowledge are defined for staff – Applicable laws and regulations are incorporated into the planning. Client name/ Presentation Name/ 12pt - 338 © Copyright, Joint Commission International SQE.1 Leaders Plan for Staff – Each staff member who is not permitted to practice independently has a job description – Job descriptions are current according to hospital policy (hospital has to define “current”) Continued on next slide Client name/ Presentation Name/ 12pt - 339 © Copyright, Joint Commission International SQE.1.1 Job Descriptions – A job description is also needed when someone – serves in primarily a managerial role, –(as in dual clinical and managerial roles, the managerial responsibilities are in a job description) – has some clinical responsibilities, for which they have not been authorized to practice independently –(as an independent practitioner learning new skills) Continued on Presentation next slideName/ 12pt - 340 Client name/ © Copyright, Joint Commission International SQE.1.1 Job Descriptions – There are also job descriptions for all who – are in an educational program and for each level of training, what can be done independently and what must be under supervision. (The program description can be the job description) – are permitted to temporarily provide services in the organization Client name/ Presentation Name/ 12pt - 341 © Copyright, Joint Commission International SQE.1.1 Job Descriptions – There is a process in place to: – Recruit staff – Evaluate the qualifications of new staff – Appoint individuals to the staff – The process is uniform across the organization – The process is implemented Client name/ Presentation Name/ 12pt - 342 © Copyright, Joint Commission International SQE.2 Recruitment – The hospital uses a defined process to match clinical staff knowledge and skills with patient needs – New clinical staff members are evaluated at the time they begin their work – The individuals department or service conducts the evaluation Continue on next slide Client name/ Presentation Name/ 12pt - 343 © Copyright, Joint Commission International SQE.3 Clinical Staff Evaluation – The hospital defines the frequency of ongoing clinical staff evaluation, but – There is at least one documented evaluation of each clinical staff member working under a job description each year or more frequently as defined by the hospital Client name/ Presentation Name/ 12pt - 344 © Copyright, Joint Commission International SQE.3 Clinical Staff Evaluation – The hospital uses a defined process to match non-clinical staff knowledge and skills with the requirements of the position – New non-clinical staff are evaluated at the time they begin their work responsibilities – The department or service conducts the evaluation Continue on next slide Client name/ Presentation Name/ 12pt - 345 © Copyright, Joint Commission International SQE.4 Non-Clinical Staff Evaluation – The hospital defines the frequency of ongoing non-clinical staff evaluation, but – There is at least one documented evaluation of non-clinical staff members each year or more frequently as defined by the hospital. Client name/ Presentation Name/ 12pt - 346 © Copyright, Joint Commission International SQE.4 Non-Clinical Staff Evaluation – Personnel information is maintained for each staff member – Personnel files contain: – Qualifications of the staff member – Job description of staff member – Work history of the staff member – Results of evaluations – Record of in-service education attended – Personnel files are standardized and kept current Client name/ Presentation Name/ 12pt - 347 © Copyright, Joint Commission International SQE.5 Personnel Files – There is a written plan for staffing the organization – The clinical and managerial leaders developed the plan collaboratively – The number, types, and desired qualifications of staff are identified in the plan using a recognized staffing method – The plan addresses the assignment and reassignment of staff – The plan addresses the transfer of responsibility from one individual to another. Client name/ Presentation Name/ 12pt - 348 © Copyright, Joint Commission International SQE.6 Staffing Plan SQE.6.1 Updating the Staffing Plan Client name/ Presentation Name/ 12pt - 349 © Copyright, Joint Commission International – The effectiveness of the staffing plan is monitored on an ongoing basis – The plan is revised and updated when necessary – All new clinical and non-clinical staff members, contract workers and volunteers are oriented to: – the organization – the department or unit to which they are assigned – their job responsibilities and any specific assignments Client name/ Presentation Name/ 12pt - 350 © Copyright, Joint Commission International SQE.7 Orientation – The hospital uses various sources of data and information, including the results of quality and safety monitoring, to identify staff education needs – Education programs are planned based on these data and information – Staff are provided ongoing in-service education and training – The education is relevant to each staff member’s ability to meet patient needs, and/or continuing education requirements Client name/ Presentation Name/ 12pt - 351 © Copyright, Joint Commission International SQE.8 In-Service Education – Staff members who provide patient care and other staff who are identified by the hospital are trained in cardiac life support – The appropriate level of training (basic or advanced) is provided with sufficient frequency to meet staff needs – There is evidence to show if a staff member passed the training – The desired level of training for each individual is repeated every two years Client name/ Presentation Name/ 12pt - 352 © Copyright, Joint Commission International SQE.8.1 Resuscitation Techniques – The hospital provides facilities and equipment for staff in-service education and training – The hospital provides adequate time for all staff to participate in relevant education and training opportunities Client name/ Presentation Name/ 12pt - 353 © Copyright, Joint Commission International SQE.8.2 Facilities and Time SQE.8.3 Health Professional Education Continue onPresentation next slide Client name/ Name/ 12pt - 354 © Copyright, Joint Commission International – Relevant to medical students, nursing students, other health professional students – Also relevant to post-graduate education (interns, residents) – The hospital – provides a mechanism(s) for oversight of the training program(s) – obtains and accepts the parameters of the sponsoring academic program – has a complete record of all trainees – The hospital – has documentation of the enrollment status, licensure or certifications achieved, and academic classification of the trainees – understands and provides the required level of supervision for each type and level of trainee – integrates trainees into its orientation, quality, patient safety, infection control and other programs Client name/ Presentation Name/ 12pt - 355 © Copyright, Joint Commission International SQE.8.3 Health Professional Education – The hospital’s leaders and staff plan the health and safety program – The program is responsive to urgent and non-urgent staff needs through direct treatment and referral – Program data is provided to the hospital’s quality and safety program Continue on next slide Client name/ Presentation Name/ 12pt - 356 © Copyright, Joint Commission International SQE.8.4 Staff Health & Safety – There is a policy on the provision of staff vaccinations and immunizations – There is a policy on the evaluation, counseling, and follow up of staff exposed to infectious diseases, that is coordinated with the infection prevention and control program Client name/ Presentation Name/ 12pt - 357 © Copyright, Joint Commission International SQE.8.4 Staff Health & Safety 358 © Copyright, Joint Commission International Credentialing and Privileging of Professionals – "credentialing:” “The process of obtaining, verifying, and assessing the qualifications of a health care practitioner. The process determines if an individual can provide patient care services in or for a health care organization or network...” – “credentials:” “Evidence of competence, current and relevant licensure, education, training, and experience.” Client name/ Presentation Name/ 12pt - 359 © Copyright, Joint Commission International What is Credentialing? – Those permitted by law, regulation, and the organization to provide patient care without supervision are identified – There is a separate record of the credentials of every medical staff member that contains copies of any required license, certification, or registration and other documents required – Licensure, certification or registrations are – Current – Documented – Verified from primary source Client name/ Presentation Name/ 12pt - 360 © Copyright, Joint Commission International SQE.9 Medical Staff Credentialing – Understand laws & regulations about employing professionals – Gather all available credentials, including at least those required – Verify from the original source every piece of evidence submitted by the candidate in support of his/her credentials. Client name/ Presentation Name/ 12pt - 361 © Copyright, Joint Commission International Intent of the Standard – Potential for falsified credentials – U.S. experience (small percentage of falsification, but frequent moves from State to State by some) – Australian experience (Dr. Patel) – Indian experience (“quackery”) – Singapore, UAE Client name/ Presentation Name/ 12pt - 362 © Copyright, Joint Commission International Why Is Credentialing an Issue? 1.Those permitted by law, regulation, and the organization to provide patient care without supervision are identified 2.Licensure, education and training are documented and verified from the primary (original) source of the document 3 . All credentials are verified at the source before the individual provides services for patients 4. Licensure, certification or registrations are current Client name/ Presentation Name/ 12pt - 363 © Copyright, Joint Commission International Some Measurable Elements of Standard SQE.9 – Means the entity that issued the document (license, certificate, or reference) – Means that the candidate cannot be part of the chain of transmission of the information from the original source of that information to the hospital Client name/ Presentation Name/ 12pt - 364 © Copyright, Joint Commission International The Original Source – By letter – By fax – By telephone call (originating from the hospital, not the source) – Websites as Original Source Client name/ Presentation Name/ 12pt - 365 © Copyright, Joint Commission International How Can the Original Source Be Reached? How to Document Original Source Verification? – Copies of letters sent and received – Notes of telephone calls made with, date and substance of call and identity of person making the call and the one responding. – Copies of web pages downloaded with date on which accessed and name of person who accessed it Client name/ Presentation Name/ 12pt - 366 © Copyright, Joint Commission International – Each physician’s file contains: Is There a Way Around This? – There are three acceptable substitutes for an organization performing primary source verification of credentials Client name/ Presentation Name/ 12pt - 367 © Copyright, Joint Commission International – Original source verification is always required; however it does not always have to be performed by the hospital – Government – Other hospitals in a hospital chain – The credentials have been verified by an independent third party such as a designated, official governmental or non-governmental agency and the hospital evaluates the agency providing the information initially and then periodically as appropriate (see criteria in Intent Statement)) – Also known as Credentials Verification Organizations (CVOs) Client name/ Presentation Name/ 12pt - 368 © Copyright, Joint Commission International Alternatives to Hospitals Doing Original Source Verification What If One Cannot Get Blood from a Turnip? – it has closed – its records have been destroyed – whatever other reason – When verification is not possible, the effort is documented Client name/ Presentation Name/ 12pt - 369 © Copyright, Joint Commission International – Original Source Verification is required by the standard – But sometimes is it simply not possible to get a University to answer, because – There is a standardized procedure to review each record at least every three years – At initial appointment and at least every three years, a determination is made about the current qualification of the individual to provide patient care services – Qualifications may be time limited – License and registration – Specialty qualifications Client name/ Presentation Name/ 12pt - 370 © Copyright, Joint Commission International Still More SQE.9 Credentialing Review – There is a standardized procedure to grant privileges to practitioners on initial appointment and on reappointment – The procedure is documented in policies, is followed, and can be demonstrated as to how privileging decisions are reached – The procedure considers sources of information as relevant to the practitioner Client name/ Presentation Name/ 12pt - 371 © Copyright, Joint Commission International SQE.10 Medical Staff Privileges Resources to Support Requested Privileges © Copyright, Joint Commission International – Step I: Is this a service our organization will offer? – Process to determine resources are in place (before deciding which privileges to grant): – Space, Equipment, Staffing, Financial resources – Step II: Where will the services happen in our organization? – Privileges can be granted only at a certain site, clinic or building where organization will provide services – Step III: What are the criteria a doctor will have to meet? – Step IV: Does the doctor’s application show evidence that he meets the criteria KEY: Must have a standardized, Client name/ Presentation Name/ 12pt - 372 evidence-based procedure! – SQE.10 ME 1 and 2: The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is based on an objective, evidence-based process (documented in policy). – This means that processes are in place for: – Developing and approving clinical privilege list – Processing application – Determining if sufficient clinical performance information is available to make a decision – If not, it may be a good idea to collect data on outcomes for time-limited period of privilege-specific monitoring (Focused Professional Evaluation – not required by the standard) Client name/ Presentation Name/ 12pt - 373 © Copyright, Joint Commission International Privileging Is an Evidence-based Process Recommendations – What to Look for – – – – – Technical and clinical skills Clinical judgment Interpersonal skills Communication skills Professionalism Client name/ Presentation Name/ 12pt - 374 © Copyright, Joint Commission International – Recommendations should include verification from peers knowledgeable about the practitioner’s professional performance – Information to seek: – Medical/Clinical knowledge “Core vs. Special” Privileges – Issue: What does “core” mean? – What is generally meant by “core”? – What must be part of any group or set of privileges? – Must be defined what task/activity/privilege listed/specified can be performed – Must be able to assess the practitioner’s ability to perform each privilege, cannot be assumed Client name/ Presentation Name/ 12pt - 375 © Copyright, Joint Commission International – Groupings of clinical privileges – Specificity of “group” varies widely (part of problem) Level I – Basic ambulatory care Level II – Level I services PLUS: – Admit adult patients into inpatient status in non-critical settings; – Perform admission history and physical examination Level III – Level II services PLUS: – Admit or transfer patients into critical care settings and act as attending physician for them, with consultation by appropriate specialists (intensivist, cardiologist, etc.) Level IV – Level III services PLUS: – Act as consultant in a particular subspecialty in internal medicine and perform specialty procedures, listed separately. Client name/ Presentation Name/ 12pt - 376 © Copyright, Joint Commission International Levels of Privileges – WHO: There is no requirement who is to make the decision, as long as it is consistent with policy – HOW: Each privilege specifically requested should be separately evaluated and “yes” or “no” decision given – Special case: “yes under supervision” Client name/ Presentation Name/ 12pt - 377 © Copyright, Joint Commission International The Decision Process – The privileges authorized for each medical staff member are made known to appropriate individuals and units of the organization and are current – In writing – By electronic means Client name/ Presentation Name/ 12pt - 378 © Copyright, Joint Commission International Communication of Privileges – On reappointment, every three years, the organization seeks and uses information in the following general competency areas of all clinical practitioners: – Patient care – Medical/clinical knowledge – Practice-based learning and improvement – Interpersonal and communication skills – Professionalism – System-based practices Client name/ Presentation Name/ 12pt - 379 © Copyright, Joint Commission International Medical Staff Credentials and Privileges Review – The organization has a standardized procedure to gather the credentials of each nursing staff member – Licensure, education, training, and experience are documented – Such information is verified from the original source according to the parameters found in the intent statement of the standard that describes physician credentialing. Client name/ Presentation Name/ 12pt - 380 © Copyright, Joint Commission International SQE.12 Nursing Staff Credentials In Other Words – Nurses’ credentials have to be verified exactly the same way as physicians’ credentials – Because they are subject to the same kind of tampering and – because an unqualified nurse can do as much harm to a patient as an unqualified doctor Client name/ Presentation Name/ 12pt - 381 © Copyright, Joint Commission International Why? Contract (Agency) Nurses Client name/ Presentation Name/ 12pt - 382 © Copyright, Joint Commission International – The organization has a process to assure that the credentials of contract nurses are valid and complete prior to assignment Special Problems with Verification of Nursing Credentials – Some countries issue nursing licenses based on university diploma only – Still need to verify the license – The standards require that no one without a license be allowed to perform tasks reserved for licensed persons – Not too many websites yet (are there any?) Client name/ Presentation Name/ 12pt - 383 © Copyright, Joint Commission International – In some countries, expatriate nurses may have to wait up to six months for a license SQE.15 Other Professionals – The organization has a standardized procedure to gather the credentials of each allied health professional staff member – Licensure, education, training, and experience are documented when relevant – Such information is verified from the original source according to the parameters found in the intent statement of the standard that describes physician credentialing. Client name/ Presentation Name/ 12pt - 384 © Copyright, Joint Commission International – In most countries, not all allied health professionals are licensed Special Problems with Verification of Other Professionals’ Credentials Then why require it? – There is evidence that false credentials in this group are more frequent than in the other two – May be as much as five times as common as false medical credentials Client name/ Presentation Name/ 12pt - 385 © Copyright, Joint Commission International – No uniformity of education or licensing laws from one type of professional to the next – No experience by hospitals in doing this kind of work for other professionals Client name/ Presentation Name/ 12pt - 386 © Copyright, Joint Commission International Next Presentation 387 © Copyright, Joint Commission International Management of Communication and Information (MCI) 1. 2. 3. 4. 5. 6. Communication with the Community Communication with Patients and Families Communication Between Providers Within and Outside the Organization Leadership and Planning Patient Clinical Record Aggregate Data and Information Client name/ Presentation Name/ 12pt - 388 © Copyright, Joint Commission International MCI – Six Areas of Focus – The hospital has – identified its communities and populations of interest – implemented a communication strategy with these populations – The hospital provides information to the community – on its services, hours of operation – on the process to obtain care – on the quality of its services Client name/ Presentation Name/ 12pt - 389 © Copyright, Joint Commission International MCI.1 Community Communication – Patients and families are given information on: – The care and services provided by the hospital – How to access services in the hospital – Alternative sources of care and services when the hospital cannot provide the care or services Client name/ Presentation Name/ 12pt - 390 © Copyright, Joint Commission International MCI.2 Patient and Family Information – Patient and family communication and education are: – In an understandable format – Provided in an understandable language Client name/ Presentation Name/ 12pt - 391 © Copyright, Joint Commission International MCI.3 Communication and Education – The leaders ensure processes are in place for communicating relevant information within and throughout the hospital in a timely manner – The leaders communicate the hospital’s mission and appropriate policies, plans, and goals to all staff – Effective communication occurs: – In the hospital among the hospital’s programs – With outside organizations – With patients and familiesClient name/ Presentation Name/ 12pt - 392 © Copyright, Joint Commission International MCI.4 Effective Communication – Leaders ensure effective and efficient communication among clinical and nonclinical departments, services, and individual staff members – Leaders foster communication in the delivery of clinical services Client name/ Presentation Name/ 12pt - 393 © Copyright, Joint Commission International MCI.5 Clinical Communication – There is a process to communicate patient information between the care providers on an ongoing basis or at key times in the care process – Information communicated includes – the patient’s health status – a summary of the care provided – the patient’s progress – (Examples: handovers from shift to shift or from a physician to on call physician) Client name/ Presentation Name/ 12pt - 394 © Copyright, Joint Commission International MCI.6 Patient Care Information – Policy establishes those care providers who have access to the patient’s clinical record – The record is available to those providers – The record is up to date to ensure communication of the latest information Client name/ Presentation Name/ 12pt - 395 © Copyright, Joint Commission International MCI.7 Medical Record Availability – The patient’s record or a summary of patient care information is transferred with the patient to another service or unit in the hospital – The summary contains: – The reason for admission – The significant findings – Any diagnosis made – Any procedures performed – Any medications and other treatments – The patient’s condition at transfer Client name/ Presentation Name/ 12pt - 396 © Copyright, Joint Commission International MCI.8 Transfer Information – The information needs of – those who provide clinical services – those who manage the organization – individuals and agencies outside the organization are considered in the planning process – The planning is appropriate to the organization’s size and complexity – (There is no written plan required) Client name/ Presentation Name/ 12pt - 397 © Copyright, Joint Commission International MCI.9 Information Management Planning – There is a written policy for addressing the privacy and confidentiality of information that is based on and consistent with law and regulation – The policy is implemented – Compliance with the policy is monitored – The hospital has a policy that indicates whether patients have access to their health information and the process to gain access, when permitted Client name/ Presentation Name/ 12pt - 398 © Copyright, Joint Commission International MCI.10 Privacy and Confidentiality – There is a written policy addressing information security, including data integrity – The policy includes levels of security for each category of data and information are identified – Those who have need or job position that permits access to each category of data and information are identified – The policy is implemented – Compliance with the policy is monitored Client name/ Presentation Name/ 12pt - 399 © Copyright, Joint Commission International MCI.11 Security and Integrity of Data and Information – The hospital has a policy on retaining patient clinical records and other data and information – The retention process provides expected confidentiality and security – Records, data, and information are destroyed appropriately Client name/ Presentation Name/ 12pt - 400 © Copyright, Joint Commission International MCI.12 Retention of Records – Standardized – diagnosis codes are used & use monitored – procedure codes are used & use monitored – definitions are used – symbols and a “do not use” listing are used & use monitored – abbreviations and a “do not use” listing are used & use monitored Client name/ Presentation Name/ 12pt - 401 © Copyright, Joint Commission International MCI.13 Standardized Terminology – Data and information dissemination meet user needs – Users receive data and information – on a timely basis – in a format that aids its intended use – Staff have access to the data and information needed to carry out their job responsibilities Client name/ Presentation Name/ 12pt - 402 © Copyright, Joint Commission International MCI.14 Disseminating Information MCI.15 Staff Participation – Managerial staff participates in information technology decisions Client name/ Presentation Name/ 12pt - 403 © Copyright, Joint Commission International – Clinical staff participates in information technology decisions MCI.16 Protection of Records – Records and information are protected from tampering and unauthorized access or use Client name/ Presentation Name/ 12pt - 404 © Copyright, Joint Commission International – Records and information are protected from loss or destruction – Decision makers and others are provided education on the principles of information management – The education is appropriate to needs and job responsibilities – Clinical and managerial data and information are integrated as needed to support decision making Client name/ Presentation Name/ 12pt - 405 © Copyright, Joint Commission International MCI.17 Principles of Information Management – There is a written policy or protocol that defines the requirements for developing and maintaining PP including at least: – Review and approval of all PP by an authorized person before issue – Process and frequency of review and continued approval of PP – Controls for ensuring that only current, relevant versions of PP are available wherever they are used – Identification of changes in PP – Maintenance of document identity and legibility – All of the above components are implemented Continue on next slide Client name/ Presentation Name/ 12pt - 406 © Copyright, Joint Commission International MCI.18 Policy on Policies – There is a written protocol that outlines how PP that originated outside the organization will be controlled, and it is implemented – There is a written policy or protocol that defines retention of obsolete PP for at least the time required by law and regulation, while ensuring that they will not be mistakenly used, and it is implemented – There is a written policy or protocol that outlines how all PP in circulation will be identified and tracked, and it is implemented Client name/ Presentation Name/ 12pt - 407 © Copyright, Joint Commission International MCI.18 Policy on Policies – A clinical record is initiated for every patient (inpatients, outpatients, emergency patients, etc) assessed or treated by the organization – Patient clinical records are maintained through the use of an identifier unique to the patient or some other effective method Client name/ Presentation Name/ 12pt - 408 © Copyright, Joint Commission International MCI.19 Clinical Records – The specific content of patient clinical records has been determined by the hospital – Patient clinical records contain adequate information to: – Identify the patient – Support the diagnosis – Justify the care and treatment – Document the course and results of treatment – See content of emergency record in MCI.19.1.1 (next slide) Client name/ Presentation Name/ 12pt - 409 © Copyright, Joint Commission International MCI.19.1 Clinical Record Content – The clinical records of emergency patients include: – Arrival time – Conclusions at the termination of treatment – The patient’s condition at discharge – Any follow-up care instructions Client name/ Presentation Name/ 12pt - 410 © Copyright, Joint Commission International MCI.19.1.1 Emergency Clinical Record – Those authorized to make entries in the patient clinical record are identified in hospital policy – The format and location of entries are determined by hospital policy – There is a process to ensure that only authorized individuals make entries in patient clinical records Client name/ Presentation Name/ 12pt - 411 © Copyright, Joint Commission International MCI.19.2 Clinical Record Entries – The author can be identified for each patient clinical record entry – The date of each patient clinical record entry can be identified – When required by the hospital, the time of an entry can be identified Client name/ Presentation Name/ 12pt - 412 © Copyright, Joint Commission International MCI.19.3 Author, Date and Time in the Medical Record – Patient clinical records are reviewed regularly – The review uses a representative sample – The review is conducted by medicine, nursing, and others authorized to make entries in patient records or manage patient records Client name/ Presentation Name/ 12pt - 413 Continue on next slide © Copyright, Joint Commission International MCI.19.4 Review of Clinical Records – The review focuses on the timeliness, legibility, and completeness of the clinical record – Record contents required by law or regulation are included in the review process – Records of active and discharged patients are included in the review process – The results of the review process are incorporated into the hospital’s quality oversight mechanism Client name/ Presentation Name/ 12pt - 414 © Copyright, Joint Commission International MCI.19.4 Review of Clinical Records MCI.20 Aggregate Data Support Client name/ Presentation Name/ 12pt - 415 © Copyright, Joint Commission International – Aggregate data and information support – patient care – organization management – the quality management program – The hospital has a process to aggregate data in response to identified user needs – The hospital provides needed data to agencies outside the organization Client name/ Presentation Name/ 12pt - 416 © Copyright, Joint Commission International MCI.20.1 Aggregation of Data – Organization has a process to participate in or use information from external data bases – Contributes data or information to external data bases according to laws or regulations – Compares it’s performance using external reference data bases – Security and confidentiality are maintained Client name/ Presentation Name/ 12pt - 417 © Copyright, Joint Commission International MCI.20.2 Information Support – Current scientific and other information supports: – Patient care – Clinical education – Research – Management – Information is provided in a time frame that meets user expectation Client name/ Presentation Name/ 12pt - 418 © Copyright, Joint Commission International MCI.21 Timely Information from Current Sources © Copyright, Joint Commission International Client name/ Presentation Name/ 12pt - 419
