Preparing for the JCIA Consultation Survey

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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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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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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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• 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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• 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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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Documents

Preparing for the JCIA Consultation Survey