JCIA Surveyor Visit 2011 Update

1. JCIA Surveyor Visit 2011Update Accreditation Section, 2011

2. JCIA Surveyors visit • JCIA Visit Dates: 09-13 April 2011 • Number of surveyors: Four (4) • Number of days: Five (5)

3. JCIA Surveyors visit Preparation Educational Material • Quality Site on the Info Gateway

4. What to expect? • Team of 4 surveyors (Administrator, 2 Physicians, Nurse)/ Stay for 5 Days • Patient Tracers – can visit all areas of the organization • May visit one area several times • Surveyor will visit the unit accompanied by escort and scribe

5. What to expect? • Surveyors want to speak to the direct care providers • Surveyor will review the medical record with the direct care provider (knowledge and practice) • Surveyors might request to interview the patient

6. Survey Visit ActivitiesSystem & Individual Tracers • Individual Patients Tracers • System Tracers: Medication, Infection Control, Facility Management & Safety and Quality & Patient safety ( Physicians & Medical Quality Directors will be asked to attend the tracers / group meetings)

7. Individual Tracer • The tracer begins where the patient is currently located • One tracer can take from 1 hr to 3 hrs • Tracer includes interviews, medical record review and observations

8. Example of a tracer Admitting process Pain management Communication Processing Critical Lab Results PI activities Pain management Nutritional referrals Falls prevention V.O / TO orders Clinical Pathway Consent process Time out Anesthesia use Infection control Process for preparation of food Special diets/referrals Pain management Process for discharging Communication Hand Hygiene practices Blood administration Restraints use Verbal Orders Communication Infection control PI activities

13. How to behave? • Welcome the surveyor to your area • Introduce yourself, explain your position and how long you’ve been working in the hospital • The surveyor wants to hear about your everyday practice (safe and competent care)

14. How do I respond to a surveyor? • Answer only what you’re asked……. • Ask for clarification if you do not understand the question • If unsure of the answer, the safest response is that you’d check the policy or ask the consultant • Reply to surveyors’ questions directly and concisely. Don’t embellish answers

15. How do I respond to a surveyor? • Answer questions with confidence and consistency- “according to policy, we”. Don’t use phrases such as, “most of the time”, “we usually”, “well, sometimes we do”. • The surveyor’s questions are based upon what should be currently in practice on a daily basis. They don’t ask misleading or trick questions meant to confuse or intimidate • Don’t give surveyors more documents than they ask for

16. How do I respond to a surveyor? • Repeat the question you’ve been asked, provides time for clarification and to formulate an answer • Be truthful, don’t try to mislead or lie to a surveyor • Maintain a professional demeanor at all times – attitude, appearance and responses

17. Confidentiality Tips • Do not discuss patient information in public areas where others can hear. Remember, all patient information whether written verbal or electronic is confidential • Log off ICIS when moving away from your computer terminal • Ensure that patient information is not left on fax machines, printers, counters • Ensure that sensitive organizational and patient information is disposed of properly; tear or shred

18. Remember • We intend to maintain a state of readiness after the survey is over • All the changes and improvements that are done are needed regardless of the survey and have to be kept up afterwards • The survey is simply a catalyst for positive change and improvement • Nothing is being done just for the survey, It is all about doing things right

19. Thank You