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Preparing for the JCIA Consultation Survey. What will be presented. AUBMC Accreditation timeline How JCIA standards are spelled out How to get ready for the consultation survey What you need to know International Patient Safety Goals. AUBMC Accreditation Timeline. - PowerPoint PPT Presentation
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Preparing for the JCIA Consultation Survey
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What will be presented
AUBMC Accreditation timeline
How JCIA standards are spelled out
How to get ready for the
consultation survey
What you need to know
International Patient Safety Goals
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AUBMC Accreditation Timeline
J an 2007 Oct 2007
Feb 2007 Mar 2007 Apr 2007 May 2007 J un 2007 J ul 2007 Aug 2007 Sep 2007
Today2007
Actual JCIA Accreditation Survey period starts
Apr 16, 2007JCIA Consultation Survey
JCIA Consultation Survey April 16 – 20th 2007
Depending on the survey findings, and after a 6 months notification period, the actual JCIA survey can be conducted
MOPH Accreditation visit is due in May 2007
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How JCIA standards are spelled out
PFR.9.4 Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures.
Intent of PFR.9.4
When the planned care includes surgical or invasive procedures, anesthesia, use of blood and blood products, or other high-risk treatments or procedures, a separate consent is obtained. This consent process provides the information identified in PFR.9.1 and documents the identity of the individual providing the information. Measurable Elements of PFR.9.4 1. Consent is obtained before surgical or invasive procedures. 2. Consent is obtained before anesthesia. 3. Consent is obtained before the use of blood and blood products. 4. Consent is obtained before other high-risk procedures and treatments. 5. The identity of the individual providing the information to the patient and
family is noted in the patient’s record.
Statement of the standard
Intent
Measurable Elements
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How to get ready for the consultation survey
AUBMC Mission Statement AUBMC policies & procedures
manual Departmental policies &
procedures manual AUBMC Safety/Emergency Plans
● Safety plan● Security plan● Hazardous material & waste
management plan● Emergency response plan● Fire safety plan● Medication equipment plan● Utility systems plan● Infection control manual
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The JCIA Standards What you
need to know
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What you need to know
Access to Care and Continuity of Care
Care planning upon admission:
• Proposed plan of care :Diagnostic tests
and or proceedures planned
• Expected results of care
• Financial cost or its expectations
Reference: Admission of Patients (ACC-MUL-001)
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What you need to know
Access to Care and Continuity of Care (cont’d)
• Admission/transfer/discharge to or from intensive/specialized care units is determined by established criteria..
Reference: Critical Care unit manual, Transfer of Patients (ACC-MUL-003)
• Attending responsible for patient care during all phases.
Reference: Transfer of Patients (ACC-MUL-003), Medical Staff Bylaws
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What you need to know
Access to Care and Continuity of Care (cont’d)
• Sharing of patient information among medical, nursing and other care providers during each staffing shift, between shifts and during transfers between units.
• Availability of patient’s medical record throughout.
• Coordination of care between diagnostic and treatment services.
Reference: Multidisciplinary Notes, Transfer of Patients (ACC-MUL-003), Medical Record Content & Documentation (MOI-MUL-003)
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What you need to know
Access to Care and Continuity of Care (cont’d)
• Discharge instructions, discharge summary. Patients records contain a copy of the Discharge Summary.
Reference: Patient Discharge Instructions (ACC-MUL-004), Medical Records Manual
• Continuity of care after transfer, sharing of information on patient condition, patient monitoring during transfer, documentation of transfer.
Reference: Transfer of Patients (ACC-MUL-003)
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What you need to know
Patient and Family Rights• Patient & family are informed of Patient Bill
of Rights and participation in care process.Reference: Patient handbook
• Confidentiality of patient informationReference: Confidentiality, Security, Privacy &
Release of Patient Information (MOI-MUL-002)
• Complaints & complements: Patients are informed about the process.
Reference: Complaints & Complements Guidelines (GLD-ADM-003); Patients Handbook
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What you need to know
Patient and Family Rights (cont’d)Informed consent: • Obtain informed consent for special procedures
(list identified).• Inform patient/family/guardian, in a
language/format that is understood, about proposed treatment for care decisions.
• Document signature of patient/family/guardian on informed consent and specify name of guardian.
Reference: Patient Consent (PFR-MUL-001)
Mission Statement:
Reference: AUBMC website & posted within AUBMC;
Patients Handbook
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What you need to know
Assessment of Patients • Medical needs are identified from the initial
assessment.• Scope and content of assessment are
defined and within the law.• Individualized assessment for special
populations.• Pain assessment is uniform.• Completion of assessment within specified
time frame.• Assessment findings are documented &
readily available. • Reassessment is done at appropriate
intervals.Reference: Multidisciplinary Assessment and
Reassessment of Patients (AOP-CLN-001)
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What you need to know
Assessment of Patients (cont’d) • Results are available in a timely
manner . • Critical test results: reporting and
documentation.Reference: Critical Test Results (COP-
MUL-018)
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What you need to know
Care of Patients• Patient care plan: Patient care is planned,
documented & revised with change of condition.
Reference: Care Delivery for all Patients (COP-MUL-008), Multidisciplinary Assessment and Reassessment of Patients (AOP-CLN-001), Medical Staff Bylaws, progress notes in patient medical record
• Physicians Orders: Those permitted to write patient orders write the orders in the patient’s record in a uniform location.
Reference: Physicians orders (COP-MUL-007), Medical Staff Bylaws
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What you need to know
Care of Patients (cont’d)Resuscitation services:• Code Team (Adult, Pediatric & Adolescents,
Neonates) Services.• Crash Carts on all in-patient units.Reference: Adult Code Team (COP-MUL-013),
Pediatric & Adolescent Code Team (COP-MUL-021), Neonatal Code Team (policy under development) (COP-MUL-022), Medical Staff Bylaws
• Blood and blood products: Process to guide the handling, use and administration.
Reference: Use of Blood/Blood Products (COP-MUL-001)
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What you need to know
Care of Patients (cont’d)• High-risk patients: Care of patients on life
support or who are comatose; care of patients with a communicable disease and immune-suppressed patients; care of patients on dialysis.
Reference: Care of High-Risk Patients (COP-MUL-017), Nursing Administration Manual (NSG-COP-059), BMT Manual, Kidney Dialysis Unit Manual
• Physical restraint:Process on the use of restraint and the care of patients in restraint.
Reference: Physical Restraint (COP-MUL-015)
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What you need to know
Care of Patients (cont’d) • Care of vulnerable patients: Process to
guide the care of vulnerable elderly patients and children.
Reference: Care of Vulnerable Patients (COP-MUL-016)
• Moderate sedation: Process to guide the care of patients undergoing moderate and deep sedation.
Reference: Moderate (Conscious) Sedation (COP-MUL-002) under development
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What you need to know
Care of Patients (cont’d) Medication Use: control of medication samples, no
patient self-administration of medications, medication orders written by certified physicians.
Reference: Physician's Orders (COP-MUL-011), Medication Samples (COP-MUL-012)
Medication errors / ADE:• Adverse medication effects are noted in the
patient’s record. • Medication errors are reported through a
process.Reference: Adverse Drug Event Reporting (COP-
MUL-004)
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What you need to know
Care of Patients (cont’d) End of life care: Assessment and
reassessment of dying patient include symptoms, the dying patient’s and family’s psychological status and spiritual needs.
Reference: End of Life Care (COP-MUL-014)
Pain assessment & management:• Pain assessment is a requirement.• Effective pain management.• Patient education on pain and pain free
hospital stay.Reference: Pain Assessment and
Reassessment (COP-MUL-005), Pain Management (COP-MUL-007)
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What you need to know
Patient and Family Education• Starts with understanding financial
implications of care choices, signing informed consent, and participating in care process.
• Educates patients on relevant topics.• Education methods appropraite to patient’s
understanding, consider the patient’s and family’s values and preferences.
Reference: Patient and Family Education (PFE-MUL-001), Patient Discharge Instructions (ACC-MUL-004), Patient Consent (PFR-MUL-001), Patient Rights & Responsibilities (PFR-MUL-002)
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What you need to know
Quality Improvement and Patient SafetyPDCA Model, indicators, medical staff
participation Reference: PI Plan (QPS-MUL-002).Incident reporting, monitoring of medical errors.Reference: Patient-Related Risk Management Plan
(QPS-MUL-001)
Prevention and Control of InfectionThe hospital wide PCI Manual is still under
development by the ICP.
Governance Leadership and DirectionDepartmental Policy and Procedure Manual, know
the content.
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What you need to know
Facility Management and Safety (manual under development )
• Fire safety: RACE, PASS, 5555
• No Smoking policy in AUBMC
• Disaster plan: 9999, participation in drills
• Hazardous Materials & Wastes: follow segregation guidelines.
• Security: safegaurd children and vulnerable patients.
• Equipment management: training on new equipment, ensure functionality before patient use.
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What you need to know
Staff Qualification and Education
• Medical Staff credentials:Reference: Re-appointment of Medical
Staff & Renewal of Clinical Privileges (SQE-MST-001)
• Continuing education: In-service training for staff, annual training for Fire Safety, BLS/ACLS/PALS training every 2 years.
Reference: Continuing Medical Education (SQE-MST-003)
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What you need to know
Management of Information
• Identification data, date, time and author of the entry in medical record.
• Error-prone abbreviations.
• Protection of records.
• Access to information in patient medical record upon each care episode.
Reference: Medical Record Content & Documentation (MOI-MUL-003)
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2007 International Patient Safety Goals
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2007 International Patient Safety Goals Poster
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Goal #1: Identify Patients Correctly
Patient Identification Policy
COP-MUL-009
Patient room number should not be used for patient identification.
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Goal #2: Improve Effective Communication
Verbal orders have to be “read back” by the receiver to check for accuracy.
Other communication methods used in AUBMC include:
Inter-shift report by nursing staff. On-service/off-service notes in
the Multidisciplinary Notes. Hand over report between house
staff. Multidisciplinary morning rounds.
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Goal #3: Improve the Safety of High-Alert Medications
Nursing & Pharmacy
Committee is working on the list of high alert
medications.
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Goal #4: Eliminate Wrong-Site, Wrong-Patient, Wrong-
Procedure SurgeryPre-operative/Pre-procedure
Verification Form: First Verification is performed by
the nurse before pre-medication. Second Verification is performed
by the nurse before the procedure. Third Verification, “TIME OUT”, is
performed just before starting the procedure.
“TIME OUT”: the nurse initiates the process, the surgeon and anesthetist verify the correct patient name, procedure and site.
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Goal #5: Reduce the Risk of Health Care-Associated
InfectionsAll AUBMC Personnel shall use proper
hand hygiene before & after:
● Patient contact
● Applying gloves for any patient related procedure such as: central- venous catheters (CVC), inserting urinary catheters, peripheral vascular catheters, or other invasive devices that do not require surgery
● Eating, drinking, preparing or handling food
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Goal #6: Reduce the Risk of Patient Harm Resulting From
Falls
Fall Risk Assessment Tool: initiated upon admission, then weekly and as condition evolves, for adults.
According to the findings, the patient is categorized as “at Risk” or “No Risk”.
If patient is at risk of fall, the patient is put on fall risk precaution.
In pediatric population, fall precaution is done daily.
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