Al Noor Jcia Add.ppt

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JCI EducationalJCI EducationalConferenceConference

AlAl--Noor Specialist HospitalNoor Specialist HospitalFebruary 21February 21--23, 200623, 2006


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Assessment of PatientsAssessment of Patients

(AOP)(AOP)


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Introduction

Primary Processes

Collect information and data on the patients

physical, psychological, social status, and health

history

Analyze the data and information to identify thepatients health care needs; and

Develop a plan of care to meet the patientsidentified needs

Performed by Qualifiedindividuals


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Introduction

Patient assessment is appropriate when itconsiders:

patients condition,

age,

health needs, and

his or her requests or preferences; and

is most effective when the variousresponsible health professionals work

together.


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Assessment Topics Initial Assessments

Scope, Content, Settings, Time Frame,Documentation, Competency, and Uniformity

Special Populations

Reassessments

Laboratory Evaluations Timely Diagnostics Hazardous Materials

Diagnostic Radiology Inter-Disciplinary Collaboration Patient Need Prioritization


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Initial Assessments

AOP.1- 1.4: All patients cared for by theorganization have their health care needs

identified through an establishedassessment process. Organization policyand procedure:

Define the information to be obtained forinpatients and ambulatory patients

Define who performs the assessment

Identifies the information to be documentedas the patient enters the organization


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Initial Assessments

Organization assessment policy andprocedure:

Based on applicable domestic laws andregulations

Completed in the time frame prescribed by the

organization, except: Medical: w/in 24 hrs and before surgery or anesthesia

Readily available to those responsible for thepatients care


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Initial Assessment - Content

AOP.2 Each patients initial assessmentincludes a physical examination and

health history. Interpretation: Hospital policy needs to be clear as to

the content of a physical assessment, whatportions may be

deferredto a later time, or deferred to another practitioner.For example, if permitted by hospital policy, an admittingconsultant can defer pulmonary system assessment to theanesthesia assessment conducted by the anesthesiologist.

The overall process must result in a complete assessment,per hospital policy, recorded on the patients record beforesurgery and anesthesia, or within 24 hours of admission.August 2003


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Initial Assessment - Settings Issue: need to be in a policy or can various

assessment forms identify, for different settings (e.g.,ambulatory or in-patient) or different patients (e.g.,

adult, pediatric), the required scope and content?

Interpretation: The list in the Survey Process Guide covers all types ofwritten documents, including forms. The most important issue is that, as the

measurable elements require, the scope and content of each type of assessmentis defined in writing. To satisfy this requirement, a form would need to beclear as to;

the health professional(s) responsible for completing the form or eachsection, and

the minimal content for the form to be considered complete in terms ofthe required assessment scope and content.

Thus, a form will usually require guidelines for completion. Such guidelinescan be on the form, or in a separate policy. The form, with guidelines, is

needed to fully meet the standards.June 2004


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Required AssessmentsWho Will Perform - Where?

In-patient Out-patient Same DayAmbulatory

Surgery

Emergency

Room

Recovery

Room

Pain (COP 19) SW

Values/Beliefs

(Religion) (PFE 1.1)SW SW SW SW NR

History (AOP 2)

Physical (AOP 2)

Psychological (AOP 2) SW SW NR

Social (AOP 2) SW SW NR

Economic (AOP 2) SW SW NR

Learning needs (PFE 1.1) SW SW SW NR

Language (PFE 1.1) SW SW NR

Nutritional risk (AOP 2.2) SW SW NRFunctional risk (AOP 2.2) SW SW NR

Discharge needs (AOP 2.4) SW SW SW NR

Other ,( e.g. pediatric headcirc, immunizations)

SW = Documented at least once in the patients record and available at

subsequent visits, but, not required for each visit.

NR = Not Required


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Initial Assessment Time Frame

AOP.2.1.1 The initial medical assessment isdocumented in the patients record within

the first 24 hours after the patients entry.The initial medical assessment is documented in

the patients record within the first 24 hours of

admission.

Initial medical assessments conducted outside theorganization are no older than six months.

Any significant changes in the patients conditionsince the report are noted in the patients record.


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Initial Assessment Surgery

AOP.2.1.2 The initial medical assessment isdocumented before the use of anesthesia or

surgical treatment.

Surgical patients have a medical assessment performedbefore surgery and documented before surgery.

Results of diagnostic tests recorded before surgery.

Preoperative diagnosis recorded before surgery.

The anesthesia assessment determines if the patient is an

appropriate candidate for the planned anesthesia. Patients are reevaluated immediately before the induction of

anesthesia.

An anesthesia assessment note is recorded before the use of

anesthesia.


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Initial Assessment - Surgery

COP.10 Each patients surgical care is

planned and documented, based on theresults of the assessment.

The surgical care of each patient is planned.

The planning process considers all availableassessment information.

The planned surgical care is documented.

A preoperative diagnosis is documented.


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Issue: the preoperative diagnosis and postoperativediagnosis are, in most cases, the same are there anyoptions for recording a postoperative diagnosis, such as

an exception process when only a different diagnosis isrecorded?

Interpretation: The options related to recording thepostoperative diagnosis along with the surgical findingsinclude: rewrite the preoperative diagnosis as a postoperative

diagnosis, write same along with the findings of the surgery, use preprinted template forms for common surgeries and only

note exceptions to what appears on the form, or


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Interpretation: develop a hospital policy and procedure that permits

documentation by exception in the absence of preprinted

template forms.

With an exception process, and whenever there is a

preliminary or tentative diagnosis, hospitalprocedure identifies how a final diagnosis is recorded,in particular when the results of pending laboratory or

other tests change an admitting or preoperativediagnosis.

June 2004


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Initial Assessments Time Frames

In-patient Out-patient Same DayEmergency

Room

Physician 24 Hours

Nurse

Physical

Therapist

RespiratoryTherapist

Nutritionist

Social Worker

Discharge

Planner


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Initial Assessment - Emergent

AOP.2.1.3 The initial medical assessmentof emergency patients is appropriate to

their needs and conditions.For emergency patients, the medical assessment

is appropriate to their needs and condition.

If surgery is performed, there is at least a briefnote and preoperative diagnosis recorded beforesurgery.


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Initial Assessment - Emergent

MOI.2.1.1 The clinical record of everypatient receiving emergency care includes:

1. the time of arrival,

2. the conclusions at termination of treatment,

3. the patients condition at discharge, and

4. any follow-up care instructions.


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Initial Assessment

Special Populations AOP.2.3 The organization conducts individualized

initial assessments for special populations cared for

by the organization.very young patients; frail elderly;

terminally ill and others in pain;patients suspected of drug and/or alcohol dependencyvictims of abuse and neglect.

COP.5.8 Policies and procedures guide the care ofvulnerable elderly patients and of children.


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Initial Assessment - Documentation

AOP.1.4 Assessment findings aredocumented in the patients record. and arereadily available to those responsible forthe patients care.

AOP.2.1 The patients medical and nursingneeds are identified from the initialassessment.


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Initial Assessment - Competency

AOP.4 Qualified individuals conduct theassessments and reassessments.

1. Individuals qualified to conduct patientassessments and reassessments are identifiedby the organization.

2. Emergency assessments are conducted byindividuals qualified to do so.

SQE.3:

Qualified: matches the requirements of theposition with the qualifications of theprospective staff member.


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Initial Assessment - Uniformity

COP.1 Policies and procedures andapplicable laws and regulations guide theuniform care of all patients.

1. The organizations clinical and managerialleaders collaborate to provide uniform careprocesses.

2. When similar care is provided in more thanone setting, care delivery is uniform.

Initial Assessment Uniformity


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Initial Assessment - Uniformity

Uniform patient care is reflected in thefollowing:

Access to and appropriateness of care and

treatment do not depend on the patients abilityto pay or the source of payment;

Acuity of the patients condition determines

the resources allocated to meet the patientsneeds;

The level of care provided to patients (for

example, anesthesia care) is the samethroughout the organization; and

Patients with the same nursing care needs

receive comparable levels of nursing carethroughout the organization.


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Initial Assessment - Scopes for

Discipline and SettingIn-

patient

Out-

patient

Same

Day

Ambulatory

Surgery

Emergency

Room

Immediately

Prior to

Induction

Recovery

Room

Special

Populations

**

Physician

Nurse

Therapist

Respiratory

Therapist

Nutritionist

Social

Worker

Discharge

Planner

Pharmacist


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Re-Assessments - progress notes

AOP.3 All patients are reassessed atappropriate intervals for their condition

A physician reassesses patients daily during the

acute phase of their care and treatment to determine their response to treatment

and to plan for continued treatment or discharge

reassessments are documented in the patientsrecord.


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Problems with Reassessments

Survey methods include staff interviews andreview of documents (policies and procedures,

and/or active and closed patient records.

Survey Findings include:Only 50% compliance

Compliance issues included poor policy

development and implementation (ME #5);and inconsistent compliance with the policies.

Progress Notes


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Progress Notes

Issue: Physicians are to assess acute care patients on adaily basis. What patients are considered acute

Interpretation: Each organization must determine

which types of patients are considered acute (bothmedical and psychiatric). rarely a clear transitionpoint it would be logical to consider that patients stillundergoing initial assessment, and patient for whom the

course of care has not yet been determined, are still inneed of daily physician attention, as opposed to normaldelivery, elective oral and maxillo-facial surgery, andothers. Surveyors will examine both the policy and practice. In

particular, the evaluation of patient records is useful todetermine that the required physician oversight occurred.

Date: September 2002

Progress Notes


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Progress Notes

Issue: Frequency of the reassessment process for acuteand non-acute patients. (AOP.3)

Interpretation: All patients are reassessed daily

during the acute phase of their care. Hospital policyidentifies those patient groups considered acute. Non-acute patients are assessed at a frequency consistent withgood clinical practice.

Hospital policy can define a specific frequency forreassessment of these patients, or

can set a range, consistent with what the Medical AdvisoryBoard considers good practice. (Each physician can thendecide the frequency of reassessment based on this range, andconsistent with the condition of his or her patient. )

Date: August 2003

R A t


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Re-Assessments Time Frames

In-patient Out-patient Same DayEmergency

Room

Recovery

Room

Physician Daily

Nurse

Physical

Therapist

Respiratory

Therapist

Nutritionist

Social Worker

Discharge

Planner

Laboratory & Radiology


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Available AOP.5.1 (6.1)Clinical pathology

(diagnostic imaging) services are provided

by the organization to meet patient needsor are readily available througharrangements with outside sources.

AOP.5.12 (6.10) The organization has

access to experts in specialized diagnosticareas when necessary.



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Timely AOP.5.4 (6.4) Laboratory (Radiology) results

are available in a timely way as defined by theorganization. Established expected turn-around times

Time frames designed to meet patient needs

ACC.1.4 Diagnostic tests for determiningpatient need are completed and used asappropriate to determine whether the patient

should be admitted, transferred, or referred.

Laborator & Radiolog S f t


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Laboratory & Radiology - Safety

AOP.5.2 (6.2) A laboratory (radiology)safety program is in place, followed, and

documented. support compliance with applicable standards and

regulations

handling and disposal of infectious and hazardousmaterials

availability of safety devices

the orientation of all staff to safety procedures andpractices in-service education for new procedures hazardous

materials.

Laboratory & Radiology S f t


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Laboratory & Radiology - Safety

FMS.5 The organization has a plan for theinventory, handling, storage, and use ofhazardous materials and the control anddisposal of hazardous materials and waste. handling, storage, and use inventory of hazardous materials and waste;

reporting and investigation of spills, exposures, andother incidents;

proper disposal of hazardous waste;

proper protective equipment and procedures duringuse, spill, or exposure; documentation, including any permits, licenses, or

other regulatory requirements

proper labeling of hazardous materials and waste.

Laboratory & Radiology Q lit


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Laboratory & Radiology - Quality

AOP.5.11 The organization regularlyreviews quality control results for all

outside sources of laboratory services. Even if it is an Accredited laboratory

QPS.3.2 Clinical monitoring includeslaboratory & radiology safety and qualitycontrol programs.

QPS.3.6 Clinical monitoring includes useof blood and blood products.

Radiation Safety


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Radiation Safety

AOP.6.2 A radiation safety program is inplace, followed, and documented.

applicable standards, laws and regulations; handling and disposal of hazardous materials availability of appropriate safety protective devices orientation continuing in-service education

QPS.3.2 Clinical monitoring includesradiology safety and quality controlprograms.

Inter Disciplinary Collaboration


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Inter-Disciplinary Collaboration

AOP.7 Medical, nursing, and other individualsand services responsible for patient carecollaborate to analyze and integrate patient

assessments.

A patient benefits most when the staff responsiblefor the patient works together to analyze theassessment findings and combine this informationinto a comprehensive picture of the patientscondition. From this collaboration, the patients

needs are identified, the order of their importanceis established, and care decisions are made.

Inter Disciplinary Collaboration


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Inter-Disciplinary Collaboration

ACC.2.2 Information about the patientscare and response to care is shared

among medical, nursing, and other careproviders during each staffing shift,between shifts, and during transfers

between units. COP.2.4 Each care provider has access

to the patient care notes recorded byother care providers, consistent withorganization policy.

Patient Need Prioritization


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Patient Need Prioritization

AOP.7.1 The most urgent or importantcare needs are identified.

Formal treatment team meetings, patientconferences, and clinical rounds may beappropriate for patients with complex or unclear

needs. The patient, his or her family, and otherswho make decisions on the patients behalf areappropriately included in the decision process.

ACC 1.1 Patients with emergency orimmediate needs are given priority forassessment and treatment.


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Questions?

Comments?

Discussion?


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JCI EducationalJCI Educational

ConferenceConference

AlAl--Noor Specialist HospitalNoor Specialist Hospital2121--23 February 200623 February 2006


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Staff Qualifications andtaff Qualifications and

Education (SQE)Education (SQE)

St ff Q lifi ti &


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Staff Qualifications &

Education

Coordinated, uniform & efficient process torecruit, evaluate, appoint & retain qualified

staff to fulfil l mission & meet patient needs:


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Planning Staffing

Process to identify job requirements & match

staff with patient needs


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Planning Staffing

SQE.3

Process to identify job requirements & match

staff with patient needs:


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Planning StaffingSQE.4.

Collaborative process by leaders to develop

written staffing plan using accepted method:

Orientation & Education


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SQE.5

Process developed to assure orientation fornew staff, contract workers & volunteers:

Orientation includes

General orientation to organization Role of individual in organization

Specific responsibilities of job/position

Safety & reporting of medical errors

Infection control practices

Organization policies/ procedures


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Orientation & EducationSQE.6

Process for staff to advance skills/knowledge

through documented education/ training:

Training is relevant to staffs ability tomeet patient needs Resources to support staff education

and training


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SQE.6.2

Assess staff ongoing learning needs based on

available data and develop organizational plan


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Medical StaffSQE.7

Effective process to gather, verify & evaluatecredentials of medical staff as primary person

responsible for patient care/ outcomes:

Evaluate qualifications & privileges permitted

by law/regulation & organization


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Medical StaffSQE.7, ME.3

Process to authorize admitting privileges tocare for patients based on qualifications:Document physicians credentials in file &

verify using original source


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Medical StaffSQE.8

Process to authorize individuals to admit

and care for patients

Licensure, education, training, andexperience are used to authorize

Services to be provided are made known

Medical Staff


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Medical Staff

SQE.9

MS participate in organizations qualityimprovement activities

Performance of individuals is reviewed

when indicated by quality improvementactivities

Performance of individual MS is reviewed

periodically, as established by

organization


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Nursing StaffSQE.10

Effective process to gather, verify & evaluatecredentials & qualifications of nursing staff

to provide direct patient care:

Evaluate qualifications permitted by law/

regulation & organization


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Nursing StaffSQE.10 and SQE.11

Effective process to gather, verify & evaluatecredentials & qualifications of nursing staff

to provide direct patient care:

Document nurses credentials in file & verify

from original source

Assign clinical work based on credentials


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Nursing StaffSQE.12

Nursing staff participate in organizations

quality improvement activities

Performance is reviewed when indicatedby findings of quality improvement

activities

Other Health Professional Staff


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SQE.13

Effective process to gather, verify & evaluatecredentials of other health professional staff

to provide patient care & services:





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SQE.13 and SQE.13.1 Effective process to gather, verify & evaluatecredentials of other health professional staff

to provide patient care & services:Document credentials in file & verify from

original source, e.g. Nurse Midwives,

Pharmacists & pharmacy technicians

Surgical assistants

Emergency medical specialists

Traditional healers & alternative medical

practitioners (acupuncture, herbal medicine)



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SQE.15

Other Health Care Professionals participate

in organizations quality improvement

activities


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Questions?

Comments?

Discussion?


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JCI EducationalJCI Educational

ConferenceConference

AlAl--Noor Specialist HospitalNoor Specialist HospitalFebruary 21February 21--23, 200623, 2006


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Staff Qualifications andtaff Qualifications and

Education (SQE)Education (SQE)

Staff Qualifications &


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Education

Coordinated, uniform & efficient process to

recruit, evaluate, appoint & retain qualified

staff to fulfil l mission & meet patient needs:


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Planning StaffingProcess to identify job requirements & match

staff with patient needs


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Planning StaffingProcess to identify job requirements & match

staff with patient needs:


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Planning StaffingCollaborative process by leaders to develop

written staffing plan using accepted method:


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Orientation & Education Process developed to assure orientation for

new staff, contract workers & volunteers:

Orientation includes

General orientation to organization Role of individual in organization

Specific responsibilities of job/position

Safety & reporting of medical errors Infection control practices

Organization policies/ procedures


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Orientation & EducationProcess for staff to advance skills/knowledge



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Orientation & Education Process for staff to advance skills/knowledge


Assess staff ongoing learning needs based onavailable data & develop organizational plan


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Medical Staff Effective process to gather, verify & evaluate

credentials of medical staff as primary personresponsible for patient care/ outcomes:

Evaluate qualifications & privileges permitted

by law/regulation & organization


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Medical Staff Process to authorize admitting privileges to

care for patients based on qualifications:Document physicians credentials in file &

verify using original source


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Nursing Staff Effective process to gather, verify & evaluate

credentials & qualifications of nursing staffto provide direct patient care:




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Other Health


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Professional Staff



Document credentials in file & verify fromoriginal source, e.g. Nurse Midwives,

Pharmacists & pharmacy technicians Surgical assistants

Emergency medical specialists

Traditional healers & alternative medicalpractitioners (acupuncture, herbal medicine)

Other Health


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Professional Staff

Effective process to gather, verify & evaluatecredentials of other health professional staffto provide patient care & services

Other Health


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Professional Staff



Participate in quality management &improvement activities, as needed


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Questions?

Comments?

Discussion?


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Establishing AccreditationScoring Process and Decisions

Key principles of scoring


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methodology Measurable and objective standards

Prioritize standards

Scoring strategy easily understandable

Key principles of scoring


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methodology Aggregate scoring rules to distinguishorganizational performance

Decision rules for non-clear situations

Scoring guidelines for evaluators and

organizations for consistency

JCI STANDARDS


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368 Standards in 11 Functional areas

198 Core standards

170 Non-core Standards

1035 Measurable Elements (ME)

599 MEs of core standards

436 MEs of non-core standards

Judging & Scoring


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Met

Partially Met Not Met

Not Applicable Data Sources

Achievements

Observations

Total Score

SCORING OF STANDARDS


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Each Measurable Element is scored

10 (full compliance), 5 (partial compliance) or

0 (no compliance)

For each Standard, the score is the

average of all Measurable Elements ofthe Standard

SCORING OF STANDARDS


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All Core Standard scores are averaged

for an Aggregate Core Standard Score

All Non-core Standard scores are

averaged for an Aggregate Non-core

Standard Score

Scoring Rules


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Track record required for scoring full

compliance or Met: Successfullyimplemented

Initial Surveys 4 month track record

Triennial Surveys 12 month track record

Scoring Rules


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Partially Met: Implemented but no track

record and is sustainable in minds of

surveyors

Not Met: Not Implemented

Judging & Scoring


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Track Record

Process Implemented for Required Period(Documented 4 months initial survey or 12 months for

tri-annual survey)

Fully Meets the Standard

Process Implemented with Improvements

Over Time

New Process is Judged to be Sustainable

Fully Meets the Standard

Questionable if New Process is Sustainable

(needs evidence)

Judging & Scoring


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Track Record

Meet Standard Most of the Time, but not

Always

Standard Expects 100% Compliance, or is High

Risk Activity

Partially or Does not Meet

Standard Does Not Demand 100% Compliance,

or is Low Risk

Partially Meets

Not Implemented, No Evidence, or Not

Sustained

Scoring Rules


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Accredited: This decision results when an

organization meets the following conditions:

The organization demonstrates acceptable

compliance with all core standards.

Acceptable compliance is: At least a score of 5 on all core standards, and

No more than one 0 in the measurableelements of a core standard, and

An aggregate score of 9 on core standards.

Scoring Rules


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The organization demonstrates acceptable

compliance with all non-core standards.

Acceptable compliance is:

An aggregate score of 7 on non-core standards. Any required follow-up requirements have been

met.

Scoring Rules


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Accreditation Denied: This decision resultswhen an organization meets one or more of

the following conditions at the end of the 6month follow-up period to a fullaccreditation survey, or the end of the 2

month follow-up period for a triennialsurvey.

One or more core standard is scored less thana 5.

Two or more measurable elements of a corestandard are scored 0.

The aggregate score for core standards is less

Scoring Rules


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This decision results when JCI withdraws

the accreditation of an organization or when

the organization voluntarily withdraws from

the accreditation process.

FOLLOW-UP REQUIREMENTSFOR

CORE STANDARDS


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CORE STANDARDSAccreditation is deferred and a written follow-up report and/or a focused survey is

required if any Core Standard has:

more than one Measurable Element scored a

0 (no compliance) or a score for the Standard of less than 5.

FOLLOW-UP REQUIREMENTSFOR

NON CORE STANDARDS


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NON-CORE STANDARDSAccreditation may or may not be deferredand a written follow-up report and/or a

focused survey is required if any Non-core

Standard has:

A non-core standard scored 0, that is, all of its Measurable Elements are

scored 0 (no compliance).

FOLLOW-UP PROCESS

Written report is req ired ithin 6 months for


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Written report is required within 6 months for

standards that require:

a plan, policy or procedure, ordocumentation.

surveyor observation, staff or patientinterviews, or the inspection of the

physical facility.

If both are required, written report is

reviewed at time of focused survey.

A single 3 month extension may be given at

Summary of ACCREDITATIONDECISIONS


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Accredited (all of three conditions are

met) Acceptable compliance with all Core

Standards

Acceptable compliance with all Non-core

Standards

All Follow-up conditions are met

Summary of ACCREDITATIONDECISIONS

A dit ti d i d


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Accreditation denied

Any one or more of three conditions are not

met

The hospital withdraws from process once it

was initiated JCI Board withdraws accreditation for cause

ummary - CCEPTABLECOMPLIANCE WITH CORE

STANDARDS


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STANDARDS At least a score of 5 on all (each) corestandards

No more than one 0 in the Measurable

Elements of any one core standard

An Aggregate Score of 9.0 or more on corestandards

ummary - CCEPTABLECOMPLIANCE WITH NON-

CORE STANDARDS


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CORE STANDARDS

An aggregate score of 7.0 or more

Issues in scoring strategies

C i t t li ti f i t t


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Consistent application of scoring strategy

Complex decision rules, hard to apply


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Guidelines for Evaluators

Report Writing

Report Writing &

DocumentationD ib D t S U d


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Documentation Describe Data Sources Used

Clearly Describe How and Why

Organization Did Not Fully Meet the

Standard

Report Writing &

DocumentationS ti D t ti


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Documentation Supportive Documentation -Quantitative when Possible

4 of 6 clinical staff interviewed

In 7 of 10 open records and 3 of 5 closedrecords reviewed, the admission assessment

was not done within 2 hours from the

patients time of arrival. In 2 of the records,there was no documented provisional

diagnosis.

Report Writing &

Documentation


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Documentation Give Credit For Progress Made

Try to Include a Positive Comment

Staff were not trained on the standard.VS

The process was clearly

interdisciplinary, and included all of thenecessary elements, but staff were not

able to identify the policy.

Report Writing &

Documentation


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Documentation Be clear and concise: hospital knows

exactly what they need to do to meetthe standard

Legible with Appropriate Grammar

Report Writing &

DocumentationS if D t S ( )


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Documentation Specify Data Source(s)Staff Interviews, Patient Interviews, Open

Journal/Record Reviews

Recognize Achievements The hospital has recently hired a new

clinical officer to address a staffing shortage

which affected the hospitals abil ity toassess patients in a timely manner.

Documents

Al Noor Jcia Add.ppt