joint commission readiness riley lunch and learn michele saysana, md august 18, 2010
TRANSCRIPT
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Joint Commission Readiness
Riley Lunch and Learn
Michele Saysana, MD
August 18, 2010
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The Joint Commission (TJC)
• Formerly know as JACHO
• Accredits health care organizations based on quality and safety standards
• Findings are made public
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How do they evaluate us?• 12-14 surveyors, 1 week, every 3 years
• IU, Riley, and Methodist
• Tracer Methodology– Follow a patient through the system– Nursing, Physicians, Environment of Care,
Pharmacy, Human Resources
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Quick Tips• Be polite
• Do NOT run from a surveyor
• Use your resources – Little red book– Emergency Reference Info tag– 2010 National Patient Safety Goals
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Orders
• ALL orders need to have – Date– Time– Legible name– Dictation number
• PRN orders must have a indication– Pain, fever, etc.
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Verbal Orders
• All verbal orders MUST be signed within 48 hours
• We are at ~80% compliance
• Sign in Cerner on Orders tab
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Fast Facts
What do you do if there is a fire in the hallway right now?
Rescue Activate Contain Evacuate
Pull the pin Aim Squeeze Sweep
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Culture of Safety Survey
• Strengths– Teamwork – Leadership expectations and actions promote
safety
• Areas for improvement– Handoffs and transitions– Feedback and communication about error
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Medications
• All syringes must be labeledlabeled– Drug– Concentration– Amount in the syringe
• Exception – if you are giving the medication as soon as you draw it up
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Culture of Safety Survey
• Annual, nationwide survey
• Identifies hospital employees and medical staff perception of safety
• Riley’s overall grade 81%81%– Best of IU/RI/MH
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Fast Facts
Who do you ask to be paged if you need security called? (i.e. the codename)
Dr. ArmstrongDr. Armstrong
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OPPE
• Ongoing Professional Practice Evaluation
• Monitoring of Medical Staff performance in relation to measures identified by each service
• Coordinated by Clarian Medical Staff Office
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FPPE
Focused Professional Practice Evaluation – New medical staff members– Existing members granted new privileges– If identified trends in OPPE
• Review based on service/specialty
• Coordinated by Clarian Medical Staff Office
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Fast Facts
Where should your ID badge hang?
Above the waist
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Performance Improvement
PI = QI = CQI = Quality Improvement
TJC uses PI to refer to performance improvement
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So what are our Riley PI projects?
• Hand Hygiene
• Handoffs/Transitions– Nurse bedside report– Resident Handoffs
• CaBSI – Catheter associated blood stream infections
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So what are our Riley PI projects?
• Asthma Action Plans– 100% compliance at Riley
• ID Bands – improving the rate of proper patient identification– Decreased the error rate from 18% to 5%
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Fast Facts
What are 3 ways to promote patient confidentiality?
Do NOT discuss patients in public
No names on white boards
Log off Cerner, Careweb, Synapse when not in use
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Infection Control• Wash hands when entering and exiting
rooms
• Follow directions on isolation signs
• Wear PPE when exposed to bodily fluids
• Clean stethoscope between patients
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Consent
All procedural consents MUST include: – Procedure– Name of Treating Practitioner– Patient’s name either printed or labeled on the
consent– Patient or patient’s representative sign, date,
& time consent– Treating practitioner’s signature and date
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Universal Protocol
• Procedural site labeling – including laterality must be performed.
• Procedural Time Outs– Stop activity– Focus on the TIME OUT– OR, bedside, treatment room, ED
• Completed Consent MUST be on chart
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Fast Facts
Name the 3 Disaster Codes
Code BlueBlue – medical emergency
Code Red Red – fire
Code AdamAdam – infant/child abduction
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• After the patient has the opportunity to recover from anesthesia
• Within 48 hours of the procedure ending
• MUST be documented in the medical record
Post-Anesthesia Evaluation
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Operative Note
• Immediate post-procedure noteImmediate post-procedure note MUST be documented following all procedures and include: – Names of the primary surgeon and assistants– Preoperative and postoperative diagnosis – Technical details of procedure– EBL– Specimens removed – Description of findings– Condition of the patient at the end of the procedure
• Dictated operative notesDictated operative notes MUST be completed within 48 hours of the procedure
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Restraint Orders
The Joint Commission and CMS have very specific guidelines for restraint use.
Restraint Orders• Cannot have a start and stop time per day.• Cannot have a “trial off” period.• Need new order each and every time a restraint is
restarted. • Continual use of restraints needs to have a daily
restraint order.
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Fast Facts – Last One!
Name 2 National Patient Safety Goals
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Fast Facts – Last One!1. Improve accuracy of patient identification2. Improve communication among caregivers3. Improve safety of medication use4. Reduce risk of healthcare associated
infections5. Accurate medication reconciliation6. The organization identifies safety risks7. Universal Protocol to prevent wrong
site/wrong procedure/wrong patient surgery