The Joint Commission: November 2010

1. The Joint Commission: November 2010 Department of Pediatrics National Naval Medical Center Bethesda, Maryland

2. What is The Joint Commission (TJC)? • “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” • Voluntary survey • Evaluates: • Compliance with Joint Commissions standards • Compliance with National Patient Safety Goals • Compliance with internally established standards and guidelines

3. The Surveyors • Life Safety Specialist: John DiGirolomo, CHFM • Field Rep: Wendel J. Schmitt, FACHE • Physician: Marvin Kolb, MD, KS, FAAP, FACPE • John E. Eiland, RN, BSN, MS

4. Tracer Methodology: The TJC tool • The tracer methodology traces a number of individuals through the organization’s entire health care process. • Opportunity to examine our documentation, processes, hand-offs • Can lead to examination of clinical activity files, credentialing, infection control data • They will interact with all levels of providers: corpsman to attending staff

5. Surveyor Truths • Focused on Patient Safety • Seeking evidence of compliance to elements of performance • Seeking documented evidence of quality processes • Assess for variation in processes • Seek to identify the systems issues related to the above • Seek to provide consultation, education and suggestions • Seek to learn

6. Variation Responses • Staff often answer questions with variation described as part of the process. e.g., “I usually…” “we often…” “If night shift does it then…” “I guess…” • Avoid this type of answer whenever possible as it leads to the need for further questioning to determine if the process is stable. • Use statements that describe less variation e.g., “Our procedure is…” “An assessment requires…” “We have guidelines that…” • Do not guess, fog, or evade.

7. Responses • Express that you feel anxious. • Relax – You can’t blow the survey for your organization. • Take a deep breath. • Seek clarification to get grounded. • “Let me get the chart.” • If you think you’ve answered the question, just stop. The surveyor will ask you another question if they need more information • Engage the surveyors on best practices. They like to share what they know to be best

8. What you should be doing NOW • Review the 2010 JC Readiness Guide • Review NNMC Annual Plan • Review PI projects • Know the NPSG’s that affect your day to day activities • Complete all outstanding records by 10 Nov • Assure H&P’s are signed within 24 hours • Daily attending notes on chart • Advance Directives summarized in chart if not available

9. What you should be doing NOW • Informed Consent with legible signature, name printed or stamped • Universal protocol for all procedures: confirm patient with 2 identifiers ,confirm site/side/procedure, and conduct a time out. Document universal protocol was done. • Wash your hands on the way in and out of all patient rooms! • Scrub your current records for “Do not use” abbreviations! • Be sure to have only 1 parameter on range orders, not both dose and time!

10. What you should be doing NOW • Review all current inpatient charts. • Check for errors that have been copied forward from note to note • Ensure care plan at the bottom of the notes are consistent • H & P to be cosigned within 24 hours. • Initial consults should be signed by the staff and then subsequent notes should say seen/discussed with and the staff name. • Be sure that all PHI/PII is secured, particularly at the end of the day • Remind staff of electronic patient safety reporting: “PSR” icon on the intranet for errors and near misses

11. NPSG in the Ambulatory Setting • Identify patients correctly • Use 2 patient identifiers • Use medication safely • Label all medications, date all multi-use vials • Prevent infection • Hand hygiene • Check patient medications • Med Reconciliation • Give patients a list of medications • Be sure Fire Doors are NOT propped open

12. Questions?