Joint Commission Readiness Riley Lunch and Learn Michele Saysana, MD August 18, 2010

1. Joint Commission Readiness Riley Lunch and Learn Michele Saysana, MD August 18, 2010

2. Formerly know as JACHO Accredits health care organizations based on quality and safety standards Findings are made public The Joint Commission (TJC)

3. 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 How do they evaluate us?

4. Be polite Do NOT run from a surveyor Use your resources Little red book Emergency Reference Info tag 2010 National Patient Safety Goals Quick Tips

5. ALL orders need to have Date Time Legible name Dictation number PRN orders must have a indication Pain, fever, etc. Orders

6. All verbal orders MUST be signed within 48 hours We are at ~80% compliance Sign in Cerner on Orders tab Verbal Orders

10. What do you do if there is a fire in the hallway right now? RescueActivateContainEvacuate Pullthe pinAimSqueezeSweep Fast Facts

11. Strengths Teamwork Leadership expectations and actions promote safety Areas for improvement Handoffs and transitions Feedback and communication about error Culture of Safety Survey

12. All syringes must be labeled Drug Concentration Amount in the syringe Exception – if you are giving the medication as soon as you draw it up Medications

13. Annual, nationwide survey Identifies hospital employees and medical staff perception of safety Riley’s overall grade 81% Best of IU/RI/MH Culture of Safety Survey

14. Who do you ask to be paged if you need security called? (i.e. the codename) Dr. Armstrong Fast Facts

15. Ongoing Professional Practice Evaluation Monitoring of Medical Staff performance in relation to measures identified by each service Coordinated by Clarian Medical Staff Office OPPE

16. 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 FPPE

17. Where should your ID badge hang? Above the waist Fast Facts

18. PI = QI = CQI = Quality Improvement TJC uses PI to refer to performance improvement Performance Improvement

19. Hand Hygiene Handoffs/Transitions Nurse bedside report Resident Handoffs CaBSI– Catheter associated blood stream infections So what are our Riley PI projects?

20. Asthma Action Plans 100% compliance at Riley ID Bands– improving the rate of proper patient identification Decreased the error rate from 18% to 5% So what are our Riley PI projects?

21. 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 Fast Facts

22. Wash hands when entering and exiting rooms Follow directions on isolation signs Wear PPE when exposed to bodily fluids Clean stethoscope between patients Infection Control

23. 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 Consent

24. Procedural site labeling – including laterality must be performed. Procedural Time Outs Stop activity Focus on the TIME OUT OR, bedside, treatment room, ED Completed ConsentMUST be on chart Universal Protocol

25. Name the 3 Disaster Codes CodeBlue– medical emergency CodeRed – fire CodeAdam– infant/child abduction Fast Facts

26. After the patient has the opportunity to recover from anesthesia Within 48 hoursof the procedure ending MUST be documented in the medical record Post-Anesthesia Evaluation

27. Immediate 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 notes MUST be completed within48 hours of the procedure Operative Note

28. 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. Restraint Orders

29. Name 2 National Patient Safety Goals Fast Facts– Last One!

30. Improve accuracy of patient identification Improve communication among caregivers Improve safety of medication use Reduce risk of healthcare associated infections Accurate medication reconciliation The organization identifies safety risks Universal Protocol to prevent wrong site/wrong procedure/wrong patient surgery Fast Facts– Last One!