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

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 goalsGoal: 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 unit4. IU Write international unit


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)


7. MS Write morphine sulfate or magnesium sulfate

8. MS04 Write morphine sulfate9. MgSO4 Write magnesium sulfate10. Ug Write mcg or micrograms11. Cc Write ml or milliliter12. T.I.W. Write 3 times weekly

or three times weekly

JCAHO Hospital Safety GoalsGoal: 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.


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.


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 goalsGoal: 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.


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 MeasuresPercent 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




Performance Measures Percent of Heart Attack Patients Given Aspirin at

Arrival




Performance Measures Percent of Heart Attack Patients Given Aspirin at

Discharge




Performance Measures Percent of Heart Attack Patients Given Beta Blocker at

Arrival




Performance Measures Percent of Heart Attack Patients Given PTCA Received

Within 90 Minutes Of Arrival



SCOTT & WHITE MEMORIAL HOSPITAL No data

Performance Measures Percent of Heart Attack Patients Given Thrombolytic

Agent Received Within 30 Minutes Of Arrival



SCOTT & WHITE MEMORIAL HOSPITAL No data

Performance Measures Percent of Heart Failure Patients Given ACE Inhibitor

for LVSD




Performance Measures Percent of Heart Failure Patients Given Adult

Smoking Cessation Advice/Counseling




Performance Measures Percent of Heart Failure Patients Given Assessment

of Left Ventricular Function




Performance Measures Percent of Heart Failure Patients Given Discharge

Instructions




Performance Measures Percent of Pneumonia Patients Given Adult Smoking

Cessation Advice/Counseling




Performance Measures Percent of Pneumonia Patients Given Blood Cultures

Performed Before First Antibiotic Received




Performance Measures Percent of Pneumonia Patients Given Initial Antibiotic

Timing




Performance Measures Percent of Pneumonia Patients Given Oxygenation

Assessment




Performance Measures Percent of Pneumonia Patients Given Pneumococcal

Vaccination




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 skinB. Contact with environmental surfaces

in the immediately vicinity of patientsC. After glove removalD. Before entering a patient room


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


Please rewrite this these orders:1. 6.U Regular Insulin Now_____________________________

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

Documents

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