Preparing for the JCIA Consultation Survey 1 What

Preparing for the JCIA Consultation Survey 1

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 2

AUBMC Accreditation Timeline § JCIA Consultation Survey April 16 – 20 th 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 3

How JCIA standards are spelled out Statement of the standard Intent Measurable Elements 4

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 5

The JCIA Standards What you need to know 6

What you need to know Access to Care and Continuity of 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) 7

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 8

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) 9

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 (ACCMUL-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) 10

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 information Reference: 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 11

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 12

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) 13

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) 14

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 15

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) 16

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 immunesuppressed 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) 17

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 (COPMUL-002) under development 18

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) 19

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) 20

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 (PFEMUL-001), Patient Discharge Instructions (ACCMUL-004), Patient Consent (PFR-MUL-001), Patient Rights & Responsibilities (PFR-MUL 002) 21

What you need to know Quality Improvement and Patient Safety PDCA Model, indicators, medical staff participation Reference: PI Plan (QPS-MUL-002). Incident reporting, monitoring of medical errors. Reference: Patient-Related Risk Management Plan (QPSMUL-001) Prevention and Control of Infection The hospital wide PCI Manual is still under development by the ICP. Governance Leadership and Direction Departmental Policy and Procedure Manual, know the content. 22

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. 23

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) 24

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) 25

2007 International Patient Safety Goals 26

2007 International Patient Safety Goals Poster 27

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Goal #1: Identify Patients Correctly Patient room number should not be used for patient identification. Patient Identification Policy COP-MUL-009 29

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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. 31

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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. 33

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Goal #4: Eliminate Wrong-Site, Wrong. Patient, Wrong-Procedure Surgery Pre-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. 35

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Goal #5: Reduce the Risk of Health Care-Associated Infections All 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 37

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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. 39

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