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BEACHFEST 2013. WELCOME. Regulatory Requirements and Radiology. A Win-Win Format for Patient Care. The Joint Commission. (TJC). Technologists. Training Licensure Registration Continuing Education. Diagnostic Areas. Environment of Care Equipment Supplies. Environment of Care.
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Regulatory Requirements and Radiology A Win-Win Format for Patient Care
The Joint Commission (TJC)
Technologists Training Licensure Registration Continuing Education
Diagnostic Areas Environment of Care Equipment Supplies
Environment of Care A survey by the Joint Commission found building conditions so poor in Greater Southeast Community Hospital in Washington, DC, that the conditions triggered a preliminary denial of accreditation.
Contrast Media Receipt Storage Use
HIPAA Business Office Corridors Diagnostic Areas
HIPAA Twenty-seven employees from Palisades Medical Center were suspended without pay for allegedly looking at George Clooney’s medical records after he was in a motorcycle accident.
Departmental Responsibilities State Regulatory Requirements Hand Hygiene Infection Control
Emergency Operation Plan Hospital Incident Command System Critical Areas Communications Resources & Assets Safety & Security Staff Responsibilities Utilities Management Patient Clinical & Support Activities
World Health Organization The Joint Commission has a World Health Organization (WHO) contract for global field testing of the International Classification for Patient Safety (ICPS).
Improve the Accuracy of Patient Identification Use at least two patient identifiers when providing care, treatment, or services.
Improving 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 information record and “read-back” the complete order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations 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. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.
Improve the Safety of Using Medications Standardize and limit the number of drug concentrations used by the organization. Identify and, at a minimum , annually review a list of look- alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
Reduce the Risk of Healthcare-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.
Accurately and Completely Reconcile Medications Across theContinuum of Care There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.
Reduce the Risk of Patient Harm Resulting from Falls Implement a fall reduction program including an evaluation of the effectiveness of the program.
Encourage Patients' Active Involvement in Their Own Care as a Patient Safety Strategy Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.
The Organization Identifies Safety Risks Inherent in its Patient Population The organization identifies patients at risk for suicide. Note: This requirement only applies to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
Improves Recognition and Response to Changes in a Patients Condition Maintain processes for identifying and addressing changes in a patient’s condition while in the Radiology Department. Include changes in a patient’s condition and current patient status in hand-off communication.
The Organization Fulfills the Expectations Set Forth in the Universal Protocol Conduct a pre-operative verification process as described in the Universal Protocol. Mark the operative site as described in the Universal Protocol. Conduct a “time out” immediately before starting the procedure as describe in the Universal Protocol.
Objectives of Tracer Activity Follow course of care and services provided to the patient Assess relationships among disciplines and important patient care functions Evaluate performance of processes relevant to the individual
Tracer Methodology A Systems Approach to Evaluation Traces a number of patients through the organization’s entire health care process Identify performance issues in one or more steps of the process – or in the interfaces between processes Process surveyors use during on-site survey Customized to HCO Survey across services and programs Multi-level participation
Priority Focus Areas Assessment and Care/Services Communication Credentialed Practitioners Equipment Use Infection Control Information Management Medication Management Organization Structure Orientation and Training Patient Safety Physical Environment Quality Improvement Expertise and Activity Rights and Ethics Staffing
Tracer Activity Comprises 50-60% of on-site survey time Approximately 90-180 minutes in length Starts and ends in the department where tracer patient is located No mandated order for visits to care areas
Tracer Process May Include Observation of direct care Observation of medication process to include contrast media Individual or family interview Review of medical records Staff interaction Review of policy and procedures Departmental tours
WHOSE JOB IS IT? This is a story about four people named Everybody, Somebody, Anybody, and Nobody. There was an important job to be done. Everybody was sure Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry about that because it was Everybody’s job. Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn’t do it. It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done.
