JCAHO Jeopardy

1. JCAHO Jeopardy Kelly D. Young, MD, MS Harbor-UCLA Medical Center

2. JCAHO BASICS PATIENT SAFETY WORK- PLACE DOCUMEN-TATION POT-POURRI $100 $100 $100 $100 $100 $200 $200 $200 $200 $200 $300 $300 $300 $300 $300 $400 $400 $400 $400 $400 $500 $500 $500 $500 $500

3. JCAHO Basics $100 What does JCAHO stand for? Answer Hint: It’s not “Julie Comes And Hangs Out”

4. Return to Jeopardy Answer JCAHO Basics $100 Joint Commission on Accreditation of Healthcare Organizations AKA “Yes, we can close your hospital and make you seek new residencies”

5. JCAHO Basics $200 • During the JCAHO survey, the surveyors will talk primarily to: • The hospital administrators • The doctors and nurses • The patients • The LA Times Answer

6. Return to Jeopardy Answer JCAHO Basics $200 B) YOU! That’s why you’re playing this game, right? PS: “I would ask my supervisor” is always safe if you don’t know the answer.

7. JCAHO Basics $300 What is “tracer methodology”? Answer

8. Return to Jeopardy Answer JCAHO Basics $300 Surveyors analyze a hospital’s systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.

9. JCAHO Basics $400 What is HIPAA? Name one way protected health information is kept private in your department. Answer NOT HIPPO!

10. Return to Jeopardy Answer JCAHO Basics $400 • HIPAA: Health Insurance Portability and Accountability Act • States that PHI may only be used for purposes of treatment, payment, healthcare operations • HIPAA trashcan for HIPAA sensitive documents • Log out of Orchid when done viewing track • No patient info laying around in work rooms • DON’T use “5150” or “OD” when discussing pts • Don’t discuss patients in hallways or elevators • Keep curtains and doors closed and don’t let patients stare at resuscitations

11. JCAHO Basics $500 What is ORYX? Bonus $100: name one core measure of ORYX Answer

12. Answer JCAHO Basics $500 • ORYX requires hospitals to collect and submit chart abstraction or electronic clinical quality measures data each quarter • New in 2015: hospitals can choose which 6 measure sets they wish to report • Only Perinatal care remains mandatory • ED measure set include 2 measures • Median time from ED arrival to ED departure for admitted patients • Admit decision time to ED departure for admitted patients More next slide

13. Return to Jeopardy Answer continued • Acute myocardial infarction • Heart failure • Pneumonia • Surgical care improvement project • Children’s asthma care • Venous thromboembolism • Stroke • Hospital-based inpatient psychiatric services • Hospital outpatient • Immunization • Tobacco treatment • Substance use treatment • Per Clint: Harbor reporting inpt psych, ED flow, adult immunization, endoscopy, surgical care, outpatient

14. Patient Safety $100 Name one of the 2015 National Patient Safety Goals Answer

15. Return to Jeopardy Answer Patient Safety $100 • Identify patients correctly • Improve staff communication • Use medicines safely • Prevent infection • Handwashing, central line infections, post-op infections, prevent UTI s/p catheters • Use alarms safely • Identify patient safety risks (suicidality) • Left off of critical access hospital goals • Prevent mistakes in surgery • Correct side, place, procedure

16. Patient Safety $200 Name one way you reduce the risk of health-care associated infections in your department Answer

17. Return to Jeopardy Answer Patient Safety $200 • Handwashing with soap and water before AND after each patient contact • Even if you used gloves • Wash vigorously for 15 seconds • Alcohol-based hand rubs may be used if there is no visible soiling and C. diff is not suspected • Use of artificial or long fingernails is prohibited LATHER UP!

18. Patient Safety $300 How do you improve the accuracy of patient identification in your department? Answer

19. Return to Jeopardy Answer Patient safety $300 • I use TWO (2) (dos) identifiers when providing treatment, administering medications, collecting specimens, discharging the patient • Patient’s name • Patient’s MRUN • NOT patient’s room number or chief complaint (e.g. the lac in room 6)

20. Patient Safety $400 How are you improving the effectiveness of communication between caregivers? Answer

21. Return to Jeopardy Answer Patient Safety $400 • Telephone orders are read back • Verbal orders are repeated back • Critical lab values and other test results are read back • We use standardized abbreviations and avoid certain unapproved dangerous abbreviations • Preliminary radiology reads in Orchid – Overread by radiologist and we we are notified of any disagreements

22. Patient Safety $500 Name 3 of the unapproved abbreviations Bonus: where are your scheduled drugs prescription pads? Answer

23. U or u (unit) IU (international unit) Ug (microgram) 1.0 (no terminal zeros) .5 (always use a leading zero – “always lead, never follow”)) X3d (for 3 days or for 3 doses) TIW (three times weekly) qD or qoD (every day, daily, or every other day) MS, MSO4, MgSO4 (morphine sulfate or magnesium sulfate) Return to Jeopardy Answer Patient Safety $500 Bonus Answer: On my person at all times, or locked up

24. Workplace $100 Where are the fire extinguishers in the AED and PED? BONUS: Where’s the oxygen shutoff valves in case of a fire? Answer

25. Answer Workplace $100 Return to Jeopardy AED and RME PED Fire extinguishers Opposite trauma 6 and room 10 Oxygen shut off Opposite room 14, between rooms 2 and 3, opposite Trauma 7 Fire alarm wall pull Opposite Trauma 7 QI board Opposite room 3 • Fire extinguishers (they are well marked with red vertical sign on wall) • Near/across from rooms 6, 10, 23, RME 17 • Oxygen shut off • Near radio room, room 19, RME room 16, across from trauma rooms 1, 2, 5 • QI board • By RN lockers

26. Workplace $200 What color “code” would you call if you had a violent patient? Who would come? Answer

27. Return to Jeopardy Answer Workplace $200 • Code Green • Crisis Response Team responds • Does NOT include police officer • ED staff are still responsible for the patient, and should assist in restraint if necessary, while attending to own safety

28. Workplace $300 What do the RACE and PASS mnemonics stand for when there is a fire? Answer

29. Remove patients and others Alarm Contain the fire (close doors) Extinguish the fire when it is safe to do so Pull the pin Aim the nozzle at the base of the fire Squeeze the handle Sweep the nozzle from side to side Return to Jeopardy Answer Workplace $300

30. Workplace $400 What should you do in the event of a hazardous material spill?* Answer * Material more hazardous than cafeteria food, but less hazardous than anthrax

31. Return to Jeopardy Answer Workplace $400 • Rinse exposure with water • Post warning signs • Cordon off area • Consult Material Safety Data Sheet (MSDS) or call Hazardous Material Safety Office

32. Workplace $500 What are code pink, code white, code orange, code gray, and code triage? ($100 per correct answer) Answer

33. Return to Jeopardy Answer Workplace $500 • Code pink: infant / child abduction • The number afterwards refers to the age of the child, e.g. Code pink 3 • Code white: pediatric code blue • Code gray: bomb threat • Code orange: hazardous material or radiation spill / exposure • Code triage: disaster

34. Documentation $100 How do you assure that you confirmed the correct identity of the patient, and the correct site of a procedure? Answer

35. Return to Jeopardy Answer Documentation $100 Do a “time out” and document that it was done – document this in the procedure note

36. Documentation $200 What does the little M mean on the Orchid track and what do I do with it? Answer * Answer is NOT “ignore and hope it goes away”

37. Return to Jeopardy Answer Documentation $200 • Medical Screening Exam – every patient needs one • For physicians, click MSE to find the form, and click the 2 boxes “definite tx provider” and “please see chart”

38. Documentation $300 What’s wrong with this order? Motrin 600 mg PO q 6-8 hours prn pain (standard adult dose) Answer

39. Return to Jeopardy Answer Documentation $300 No range orders allowed (No range in doses, no range in time intervals)

40. Documentation $400 Which is acceptable? Answer

41. Return to Jeopardy Answer Documentation $400 • C • Signature • Last name legibly spelled out • Degree (MD, RN, PNP, etc.) • Identification number

42. Documentation $500 What’s the “fifth vital sign” that we document on ALL patients, and how can we improve in this area? Answer

43. Return to Jeopardy Answer Documentation $500 • PAIN score • SCREEN patients and order meds within 30 min of pt arrival to ED • Prescribe or suggest (in pt instructions) pain med on discharge GOALS Pain med w/in 30min Reassess w/in 30min of IV/IM pain med, w/in 60min of PO Pain score < 4 at d/c or pain med for home

44. Potpourri $100 True of False: A minor sibling may translate for the parent if the minor is 13 years old or older, clearly fluent in both languages, and the parent and minor consent to using the minor as an interpreter Answer

45. Parent “El bebe tiene mucho fiebre, hasta ciento siete, y no come nada, nunca, en todo su vida, (esos Cheetos son la primera comida de todo su vida), y tiene fiebre por dos o tres meses, y le duele todo su cuerpo, y tiene ronchas y grippe y tos y nausea y diarrea…” Sibling Interpreter “Tiene fiebre?” “Yes” Return to Jeopardy Answer Potpourri $100 So VERY VERY False!

46. Potpourri $200 Does Harbor have a mission? Answer It’s not “To get our residents more sleep and more money.”

47. Return to Jeopardy Answer Potpourri $200 Mission: to provide high quality, cost-effective, patient-centered care through leadership in medical practice, education and research.

48. Potpourri $300 What quality performance data are collected in your area, and how are you involved? Answer

49. Answer Potpourri $300 Return to Jeopardy • Look at the QI boards in AED and PED to see • Medication errors • Fall prevention • Sepsis data • Pain management • Timeouts for non-emergent procedures • Procedural sedations reviewed • Ebola screening • Individual cases highlighted for opportunities in improving medical management are reviewed for EDQI committee, and may be presented in an M&M • Residents help prepare presentation

50. Potpourri $400 Dr. X is starting his shift in the PED. He walks down the hall, Starbucks in hand, and waves “hi” to the nurses and clerk. He rounds the corner, going through the propped open door to stand in the docbox. He logs on and notes that there are 2 patients with the same last name on the track. He dumps his empty coffee cup in the trash, sets down his trusty Harriet Lane Handbook on the counter, and nudges the sleeping intern. Where’s the JCAHO violation? Answer