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JCAHO Update

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					JCAHO Update


     John D. Crossley, RN, PhD
           Why do Residents care about
                    JCAHO
It is required that an academic medical center with a residency training
     program be accredited.

   The Accreditation Council on Graduate Medical Education (ACGME)
    Institutional Requirements state: 'Institutions sponsoring participating
    GME programs should be accredited by the JCAHO, if such institutions
    are eligible.

   If an institution is eligible for JCAHO accreditation and chooses not to
    undergo such accreditation, then the institution should be reviewed by
    and meet the standards of another recognized body with reasonably
    equivalent standards. If the institution is not accredited, it must provide
    a satisfactory explanation of why accreditation has not been either
    granted or sought.'

   ACGME notes that certain specialty training programs , like general
    surgery should be conducted in institutions accredited by JCAHO.
                        http://www.aha.org/aha/key_issues/patient_safety/accreditation/
   Why do residents care about
             JCAHO
A hospital or health system that does not have deemed
status is able to participate in Federal health care programs
such as Medicare – which funds GME- but:

If a hospital or health system chooses not to be accredited
by either the JCAHO or the American Osteopathic
Association, the organization will be subject to periodic
surveys by personnel of the respective state agency that
licenses hospitals and other health care facilities (or its
equivalent). The results of such surveys will serve to
determine whether a hospital or health care system is
eligible to participate in such Federal programs as Medicare.


    http://www.aha.org/aha/key_issues/patient_safety/accreditation/
The Old JCAHO
 Scheduled months in advance
 Primarily a retrospective review
 Small teams of part-time surveyors with
  limited training
 Unstructured care area visits
 Focus on prior survey reports
 Tailored primarily to national high-
  volume diagnoses
The New JCAHO
 No scheduled surveys
 Minimal retrospective review
 Larger teams of full-time surveyors with
  extensive training
 Tracer methodology
 Global priority focus areas
 Tailored to current inpatient census
Previous Survey Process
 Structured, based on physical patient
  care areas
 Uniform across all organizations
  surveyed
 Unit/clinic visits tightly scheduled and
  controlled
 Primarily managerial staff participation
  in survey
 Main focus on policies and procedures
        New Survey Process
        Tracer Methodology
 Process-driven, directed by priority
  focus areas
 Customized to the individual health care
  organization
 Surveys follow provision of services
  across physical and programmatic
  boundaries
 Multi-level staff participation
 Main focus on actual care delivery
Priority Focus Areas
 Each standard relates to one or more
  priority focus area
 “Processes, systems, or structures in a
  health care organization that
  significantly impact the quality and
  safety of care.”    2005 CAMH
 Serve to integrate chapter elements of
  the accreditation standards
JCAHO hospital safety goals
Goal: Improve the accuracy of patient
  identification.
 Use at least two patient identifiers
  (neither to be the patient's room
  number) whenever administering
  medications or blood products; taking
  blood samples and other specimens
  for clinical testing, or providing any
  other treatments or procedures.
    JCAHO hospital safety goals
Goal: Improve the effectiveness of communication among
   caregivers.

 For verbal or telephone orders or for telephonic reporting of
  critical test results, verify the complete order or test result by
  having the person receiving the order or test result "read-
  back" the complete order or test result.
 Standardize a list of abbreviations, acronyms and symbols that
  are not to be used throughout the organization.
 Measure, assess and, if appropriate, take action to improve
  the timeliness of reporting, and the timeliness of receipt by
  the responsible licensed caregiver, of critical test results and
  values
 Standardized list of abbreviations
1.   Q.D.     Write   “daily”
2.   Q.O.D.   Write   “every other day”
3.   U.       Write   unit
4.   IU       Write   international unit
Standardized list of abbreviations

5. Trailing zero (1.0 mg)
Never write a zero by itself after a decimal point
   (1 mg)
6. Lack of leading zero (.1mg)
Always use a zero before a decimal point (0.1 mg)
Standardized list of abbreviations
7. MS       Write morphine sulfate or
            magnesium sulfate
8. MS04     Write morphine sulfate
9. MgSO4    Write magnesium sulfate
10. Ug      Write mcg or micrograms
11. Cc      Write ml or milliliter
12.T.I.W.   Write 3 times weekly or
            three times weekly
JCAHO Hospital Safety Goals
Goal: Improve the safety of using medications.

 Remove concentrated electrolytes (including, but not
  limited to, potassium chloride, potassium phosphate,
  sodium chloride >0.9%) from patient care units.
 Standardize and limit the number of drug
  concentrations available in the organization.
 Identify and, at a minimum, annually review a list of
  look-alike/sound-alike drugs used in the organization,
  and take action to prevent errors involving the
  interchange of these drugs.
JCAHO hospital safety goals
Goal: Improve the safety of using
        infusion pumps.

 Ensure free-flow protection on all
  general-use and PCA (patient
  controlled analgesia) intravenous
  infusion pumps used in the
  organization.
JCAHO hospital safety goals
Goal: Reduce the risk of health care-
  associated infections.

 Comply with current Centers for Disease
  Control and Prevention (CDC) hand hygiene
  guidelines.
 Manage as sentinel events all identified
  cases of unanticipated death or major
  permanent loss of function associated with
  a health care-associated infection.
Indications for Hand Washing
 Contact with a patient’s intact skin
 Contact with environmental surfaces
  in the immediately vicinity of patients
 After glove removal
   JCAHO hospital safety goals
Goal: Accurately and completely reconcile medications
  across the continuum of care.

 During 2005, for full implementation by January 2006,
  develop a process for obtaining and documenting a
  complete list of the patient's current medications upon
  the patient's admission to the organization and with the
  involvement of the patient. This process includes a
  comparison of the medications the organization
  provides to those on the list.

 A complete list of the patient's medications is
  communicated to the next provider of service when it
  refers or transfers a patient to another setting, service,
  practitioner or level of care within or outside the
  organization.
JCAHO hospital safety goals
Goal: Reduce the risk of patient
  harm resulting from falls.
 Assess and periodically reassess
  each patient's risk for falling,
  including the potential risk
  associated with the patient's
  medication regimen, and take
  action to address any identified
  risks.
14 Priority Focus Areas
 Assessment and Care/Services
 Communication*
 Credentialed Practitioners
     Appropriate Life Support certifications
     Valid permit or Texas license
   Equipment Use
   Infection Control
   Information Management*
   Medication Management*
Priority Focus Areas (cont.)
 Organizational Structure
 Orientation and Training
 Patient Safety
 Physical Environment
 Quality Improvement Expertise and
  Activity*
 Rights and Ethics
 Staffing
* Particular focus
Priority Focus Process
 Converts pre-survey data into:
   information to focus survey activities,
   increase consistency in the survey process,
   customize the accreditation process.
Tracer Methodology
Scott and White prepared for Tracer
  Methodology by:
 Inviting a Consultant team from Joint
  Commission Resources: physician,
  nurse, and administrator
 Nominating 48 S&W staff to be trained
 Offering a day of didactic presentation &
  one half day of a tracer demonstration
Demonstration Tracer Findings
 Food in all patient care areas
 Fragmented medical records with
  documents missing
 No hand washing
 Staff unaware of unit/clinic results on
  performance measures
 Unsecured medications
              Performance Measures
Percent of Heart Attack Patients Given ACE Inhibitor
                      for LVSD



 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  75%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 71%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 81%
               Performance Measures
Percent of Heart Attack Patients Given Adult Smoking
            Cessation Advice/Counseling



 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  75%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 73%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 91%
              Performance Measures
 Percent of Heart Attack Patients Given Aspirin at
                      Arrival


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  91%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 90%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 93%
              Performance Measures
 Percent of Heart Attack Patients Given Aspirin at
                    Discharge


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  86%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 85%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 96%
               Performance Measures
 Percent of Heart Attack Patients Given Beta Blocker at

                        Arrival


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  84%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 81%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 97%
              Performance Measures
 Percent of Heart Attack Patients Given PTCA Received

             Within 90 Minutes Of Arrival


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  37%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 38%
 SCOTT & WHITE MEMORIAL
  HOSPITAL No data
              Performance Measures
Percent of Heart Attack Patients Given Thrombolytic
   Agent Received Within 30 Minutes Of Arrival


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  37%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 28%
 SCOTT & WHITE MEMORIAL
  HOSPITAL No data
              Performance Measures
Percent of Heart Failure Patients Given ACE Inhibitor
                      for LVSD


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  74%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 73%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 76%
              Performance Measures
   Percent of Heart Failure Patients Given Adult
      Smoking Cessation Advice/Counseling

 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  65%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 62%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 44%
               Performance Measures
Percent of Heart Failure Patients Given Assessment of
              Left Ventricular Function


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  78%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 72%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 92%
              Performance Measures
 Percent of Heart Failure Patients Given Discharge
                   Instructions


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  45%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 42%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 17%
              Performance Measures
Percent of Pneumonia Patients Given Adult Smoking
          Cessation Advice/Counseling


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  61%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 58%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 26%
              Performance Measures
Percent of Pneumonia Patients Given Blood Cultures
    Performed Before First Antibiotic Received


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  82%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 79%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 83%
               Performance Measures
Percent of Pneumonia Patients Given Initial Antibiotic
                      Timing

 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  72%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 70%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 55%
              Performance Measures
 Percent of Pneumonia Patients Given Oxygenation
                  Assessment


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  98%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 97%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 98%
              Performance Measures
Percent of Pneumonia Patients Given Pneumococcal
                  Vaccination


 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE UNITED STATES
  43%
 AVERAGE FOR ALL REPORTING
  HOSPITALS IN THE STATE OF TEXAS
  - EASTERN & SOUTHERN 38%
 SCOTT & WHITE MEMORIAL
  HOSPITAL 27%
Accreditation Decision Options
   Accredited
   Provisional Accreditation
   Conditional Accreditation
   Preliminary Denial of Accreditation
   Denial of Accreditation
   Immediate Threat to Life
Demonstration Tracer Results




 Scott and White would have failed
Triaging JCAHO Standards
 “A” List
   Must do: no question, no debate
 “B” List
   Must do: can be modified to
    accommodate S&W practices
 “C” List
   Should do: JCAHO standards which, if
    not met, will result in demerits but
    not loss of accreditation
“A” List Examples
 Remove all food in patient care work
  areas
 Follow CDC guidelines for hand washing
 Use of only approved abbreviations
 Have qualified staff and equipment for
  patient population served
 Practice time outs prior to surgery and
  other invasive procedures to verify right
  patient, right procedure, right site
The End
   Please proceed to the post test
   Download the post test
   Complete the post test
   Return the post test to Dr. S.K. Oliver
    407i TAMUII
Post test question 1
Indications for handwashing include all
   of the following except:
A. Contact with a patient’s intact skin
B. Contact with environmental surfaces
   in the immediately vicinity of patients
C. After glove removal
D. Before entering a patient room
Post test question 2
Scott and White performed least well in
  which of the following performance
  areas:
A.   Percent of Heart Attack Patients Given Aspirin at Arrival
B.   Percent of Heart Attack Patients Given Beta Blocker at
     Arrival
C.   Percent of Heart Failure Patients Given Discharge
     Instructions
D.   Percent of Pneumonia Patients Given Blood Cultures
     Performed Before First Antibiotic Received
Post test question 3
 Please rewrite this these orders:
1. 6.U Regular Insulin Now
_____________________________

1. Pot chloride 10 meq 1 po QID #90
______________________________

				
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