Chief Residents’/Fellows’ Meeting on Patient Safety

JCI Preparation of Trainees

9 June 2015

Scenario on Sept 14-18,2015

• Every morning , the chief resident submits to the executive office the list of inpatients for the day. This list is given to the JCI surveyors who will conduct patient tracers.

• During the patient tracers ( ER, Nursing Unit, Radiology, ICU, OR,RR, etc ) , the health care providers will be interviewed on how they rendered care to the patient.

• Sample questions:

• How do you ensure correct patient identity?

• How do you assess patients?

• Show me your documentation of your assessment? When was this written?What is your hospital policy on patient assessment?

Scenario on Sept 14-18• Sample questions:

• What is the policy and process of transferring patients to the ICU?

• What are the criteria for admission to the ICU?

• Who secures the informed consent for surgical procedures? How is the informed consent obtained? Where is it documented?

• What is the process for discharge of patients? Show me the discharge instructions ?

• Where is the documentation of patient education ? Who educates the patients re: home medications?

Sample patients for tracer .

•

• Psychiatric patient • Pediatric and/or neonatal patient • Maternity patient • Patient receiving imaging services • Patient receiving rehabilitation services • Patients who cross programs• Patients received from another hospital, long term care ,

Patient transferred from another hospital • Patients who underwent neurosurgery• High risk pregnant patients

Staff Qualification and Education Interview• Selected 201 files of medical staff and

trainees

• Check if licenses are updated

• Check if there are CME certificates ( 2013-1015)

• Credentials: Diploma, Diplomate certificates

• Proof of Patient Safety Training ( 2015)

• Evaluation of Trainees by the departments

Open and Closed Chart Reviews

• Review of inpatient charts for completion: ( Open chart review)

• Patient Databases if all sections are filled up and signed

• Progress notes and Care plans using measurable goals

• Legible handwriting

• Printed name and signatures

• Informed consent

• Patient Education documentation

• Request forms for imaging procedures/ blood transfusion

• If medications are written properly

• If there are telephone orders

• Operative Technique/Operative Records etc

How do you prepare as PS champs? How do you prepare your trainees?

• Complete the Patient Safety training curriculum

• Study JCI guides/cheat cards

• Know the hospital policies/ department policies/unit policies( ICU, ER, Radiology , Laboratory etc)

• Practice PATIENT SAFETY THINKING all the time

• Endorse patients ( hand-offs)

• Document assessment, reassessment and care plans using measurable goals

• Documentation including printed name and signature

• Supervise the medical students and junior residents /fellows

• Know your patients

• Complete your medical records including Discharge summaries on time

• Submit your CME certificates and all MTO requirements/ update licenses /BLS/ACLS

Scenario 3-5 years from now• You are Diplomates of your specialty practicing in the TMC network ( hospitals

and clinics). You carry the TMC Brand of care wherever you go.

• You practice patient safety thinking and behavior in all your health care activities

• You assess your patients promptly and thoroughly

• You document all your assessment findings

• You document your care plans and explain to the patient and family

• You hold team and family meetings if necessary

• You always use patient identifiers

• provide your patients with complete discharge instructions including discharge summary

• You sign all your orders and write legibly on the chart

• You COMMUNICATE with patients and INVOLVE them in their care

• You are champions /role models of Patient Partnership