Joint Commission Readiness

Riley Lunch and Learn

Michele Saysana, MD

August 18, 2010

The Joint Commission (TJC)

• Formerly know as JACHO

• Accredits health care organizations based on quality and safety standards

• Findings are made public

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

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

Orders

• ALL orders need to have – Date– Time– Legible name– Dictation number

• PRN orders must have a indication– Pain, fever, etc.

Verbal Orders

• All verbal orders MUST be signed within 48 hours

• We are at ~80% compliance

• Sign in Cerner on Orders tab

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

Culture of Safety Survey

• Strengths– Teamwork – Leadership expectations and actions promote

safety

• Areas for improvement– Handoffs and transitions– Feedback and communication about error

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

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

Fast Facts

Who do you ask to be paged if you need security called? (i.e. the codename)

Dr. ArmstrongDr. Armstrong

OPPE

• Ongoing Professional Practice Evaluation

• Monitoring of Medical Staff performance in relation to measures identified by each service

• Coordinated by Clarian Medical Staff Office

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

Fast Facts

Where should your ID badge hang?

Above the waist

Performance Improvement

PI = QI = CQI = Quality Improvement

TJC uses PI to refer to performance improvement

So what are our Riley PI projects?

• Hand Hygiene

• Handoffs/Transitions– Nurse bedside report– Resident Handoffs

• CaBSI – Catheter associated blood stream infections

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%

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

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

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

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

Fast Facts

Name the 3 Disaster Codes

Code BlueBlue – medical emergency

Code Red Red – fire

Code AdamAdam – infant/child abduction

• 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

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

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.

Fast Facts – Last One!

Name 2 National Patient Safety Goals

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