Joint Commission Update

1. Joint Commission Update Clinical Compliance and Risk Management Fall 2012

2. Overview BWH Survey Activity Hot Topics/Risk Areas Departmental Education Plan

3. BWH Survey Activity TJC: Hospital-wide - Window is open till February 5, 2013 CMS: CMS Validation post TJC – up to 6 months

4. Survey Plan Notification Plan Command Center Observations, Interview and Medical Record Review Surveyor Interaction – Quality and Patient Safety

5. HOT TOPICS Infection Control (sterilization, disinfection, PPE) National Patient Safety Goals Medical Record Documentation (date & time every entry, completeness) Restraints Interdisciplinary Care and Continuity Hand- Off Communication

6. Infection Prevention and Control Are staff following the signs and using PPE? Cross Contamination How is a patient’s precaution status communicated? Hand Hygiene Clean – Dirty Segregation/ CDS – cleaning, disinfection, sterilization (Manufacturing Directions for Use)

7. National Patient Safety Goals Patient Identification Reporting of Critical Test Results Medication Safety Anticoagulation Medication Reconciliation Labeling Universal Protocol Suicide Assessment Infection Prevention and Control MDRO, SSI, CLABSI and new CA-UTI

8. Documentation All entries dated, timed, signed, and legible Brief operative and procedural notes History and Physical Reassessment just prior to anesthesia induction Informed Consents complete Progress Notes daily No inconsistencies with Allergy information between disciplines Advance Care Directives/End of Life Discussions

9. Interdisciplinary Care and Communication Rounds Continuity/Consistency Communication Hand-offs

10. Medical Staff Credentialing and Privileging - OPPE/FPPE 6 General Areas of competencies: Patient care, medical-clinical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism and systems- based practice. Ongoing Professional Practice Evaluation- requires ongoing review of criteria, provides closer oversight and fosters a more evidence based privilege renewal process Focused Professional Practice Evaluation-specific focus on practitioners performance new or based on potential practice issues

11. What’s New Patient Visitation Rights - The hospital allows for the presence of a support individual of the patient’s choosing. New National Patient Safety Goal - Implement evidence based practices to prevent indwelling Catheter Associated-UTI (CAUTI)

12. Implement evidence based practices to prevent indwelling Catheter Associated-UTI (CAUTI) ED Order Entry – established guidelines BICS – prompts for removals Discontinue urinary catheters as soon as possible BWH CAUTI guidelines located on Pike Notes on the infection control page in “policies”

13. Restraints MD order obtained prior to application MD documentation of daily assessment MD documentation of one hour face to face on behavioral/violent pt. restraints Restraint Education Restraint Death Reporting

14. Life Safety and Environment of Care Clutter Clear exits No food or drink in patient care areas CODE RED - Alarm (pull stations-2-6555), Rescue, Contain, Evacuate

15. Additional Resources Pocket Booklets/Continual Readiness Page from Pike Notes http://www.bwhpikenotes.org/Employee_Resources/Compliance/readinesscentral.aspx Email Communication at Survey Time