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Relax – surveyors are physicians, nurses, medical technologists and others who have worked in hospitals. They've “been there”! • Always be honest.
Typology: Exams
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Mission, Vision, Values
Survey Overview/Priority Focus Areas Tracer Methodology
Identify goals that your area has been working on and be able to discuss
Patient Rights & Responsibilities Ethics Committee Informed Consent Advance Directives/End of Life
Privacy/Confidentiality Communication/Interpreter Services Cultural & Spiritual Sensitivity Handling Complaints
Abuse & Neglect Pain Management Interdisciplinary Care Rapid Response Team Resuscitation/Code Carts
Restraints Patient/Family Education Discharge Planning Point of Care (Waived) Testing
Access to Medications High Alert Medications Look-a-Like/Sound-a-Like Medi cations Medication Orders
Adverse Drug Reactions Medication Incidents Initiatives to Reduce Incidents
Standard Precautions
Blood Borne Pathogens/Exposure Isolation Signs
Staff Participation in PI
Reducing safety risks/FMEA Sentinel Event/Root Cause Analysis (RCA)
Culture of Safety/Quality
Managing Disruptive Behavior Communication & Safety (S●T●A●R●T)
Safety Manager Security
Hazardous Materials/Chemical Spills Medical Equipment Management Emergency Codes/Disaster (PASS) (RACE)
Orientation/Competency Staff Responsibilities
Information Needs of Staff
Key Documentation Requirements Summary Lists-Ambulatory Pts.
Privileges Medical Staff Impairment
Responsibilities
Nursing Policies & Procedures
A Joint Commission on-site accreditation survey provides an assessment of an organization’s compliance with standards and their elements of performance. The Joint Commission evaluates an organization’s compliance with standards based on:
Patient and staff interviews about actual practice Performance improvement data/trends Verbal information provided to the Joint Commission by key organizational leaders On-site observations by Joint Commission surveyors
2004 marked the beginning of a new era for Joint Commission, a new accreditation process called Shared Visions – New Pathways. One of the components of this new process is The Priority Focus Process (PFP). The PFP gathers data about an organization from multiple sources and analyzes the data using a set of defined, automated rules. Eventually, turning the data into information the surveyors can use to target areas for review during the survey.
The Priority Focus Process (PFP) has identified the following areas and patient populations for Nemours:
Rights & Ethics Assessment and Care/Services Medication Management Credentialed Practitioners
Equipment Use Information Management Physical Environment General Surgery
Cardiology Gastroenterology Nephrology
The Joint Commission uses the “Tracer Methodology” as a method of assessment. So… What can you expect?
To follow the course of care and services provided to a patient
To assess relationships and hand-offs among disciplines To evaluate processes the patient is experiencing (pain management, restraints, surgery etc.)
Patients within Priority Focus Areas ( see above )
Patients with other frequently seen diagnoses (the key populations we care for) Patients who receive complex services (often those close to discharge) Patients who cross different programs, e.g., hospital and practice. Patients who encounter these processes: Infection Control Medication Management Surgery Sedation Outpatient Care
Comprises 50-60% of on-site survey time
Will be approximately 90 minutes per patient Starts in the setting/unit where the tracer patient is located and moves to any other areas the patient has encountered or is scheduled to encounter Anticipate 2 patient specific tracers per surveyor each day of the survey
Review the medical record with staff Observe direct care Observe the medication process Observe the care planning process Assess competencies, evaluation and continuing education of staff they interacted with
Interview the patient and/or family Review additional medical records, as needed, from other settings Observe staff level interaction Observe the environment of care Discuss national patient safety goals and improvements made to patient care and services
..Keep the conversation professional.. Ask questions if you do not understand. NEVER argue with the surveyors. Be professional and use appropriate language and behaviors.
..Be truthful .. If you do not know an answer say so and tell the surveyor where or whom you would go for the answer. Remember you may use any resources available to you , such as intranet policies, any department resources, or your manager.
..Keep your answers focused and specific to their question.. Whenever possible, answer in your own words and keep answers short and to the point. KISS = K eep I t S hort & S imple
..Support your co-workers.. If you are present when someone is being interviewed, feel free to add any relevant information. Respond to questions with confidence – you know the answers better than anyone. Speak freely about all of the great things we do – and there are many!
..Other tips on professional interaction with surveyors..
Comply with WHO or CDC Hand Hygiene Guidelines
There is a process for comparing the patient’s current medications with those ordered while under the care of the organization
Implement a fall reduction program and evaluate the effectiveness of the program.
Encourage Patients’ Active Involvement in Their Own Care as Safety Strategy
Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so
Organization selects a suitable method that enables health care staff to directly request additional assistance form a specially trained individual(s) when a patient’s condition appears to be worsening
Organization identifies patients at risk for suicide
Reference: (^) Policy 60.42 – Operative/Procedural Areas Policy 60.76 – Outside the OR/Procedural Areas
Conduct a pre-operative verification process as described in the Universal Protocol
Verify correct person, procedure and site…
Use a checklist to assure you have…
Mark the operative site as described in the Universal Protocol
Conduct a “time out” immediately before starting the procedure as described in the Universal Protocol
A patient’s decision about care, treatment and services at the end of life must be appropriately addressed.
Yes. All associates are required to complete a mandatory module on Rights, Ethics & Diversity that addresses advance directives as part of orientation to the organization. In addition, all clinical associates are required to complete a mandatory module on “Providing Comfort and Dignity During End-of-Life Care” during orientation.
are asked to bring it in.
information about advanced directives.
Yes. All associates are required to complete HIPAA privacy and security training.
Place in appropriate locked receptacle in your department. PHI is NEVER to be placed in a regular trashcan.
A reasonable effort is made to tailor information to the patient’s age, language and ability to understand. The following services are offered to provide for effective communication with patients, families and visitors. Refer to policy 60.28 for full description. Call Department of Patient and Family Services at extension 4230 to access an interpreter. If an in-house interpreter is not available, utilize the Language Line Service.
Patient rights include “respecting and acknowledging one’s psychosocial, spiritual and cultural values and how they impact a patient’s response to their care.” Health care professionals are entrusted to care for patients as whole persons – body, mind and spirit. In addition, health care professionals need to be empowered with the capacity, skills, and knowledge to respond to the unique needs of each patient and their loved ones.
The Chaplain’s service is available to support patients, family and staff and may be accessed at extension 5063 or via the switchboard.
GOAL: Provide access to care; provide interventions based on the plan of care, including education, and coordinate care to promote continuity when patients are referred, discharged, or transferred.
COMPONENTS INVOLVED: Assessing Patient Needs Providing Care, Treatment, & Services Planning Care, Treatment, & Services Coordinating Care, Treatment, & Services
We provide interdisciplinary care rather than multidisciplinary (silo) care. We talk to our colleagues who are involved with the care of our patients—physicians, nurses, social workers, dieticians, therapists & others.
The Attending Physician/Attending Physician’s team must write a clearly delineated plan of care for the patient at least every 24 hours. This plan must include measurable goals (ex. continue IV fluids, get patient out of bed, consult Gastroenterology, etc.). This progress note that demonstrates the plan of care will be reviewed each day by the various disciplines that are involved with the patient’s care and will be initialed by those disciplines.
Development (^) A multidisciplinary plan of care is developed based on assessed patient needs/ goals
Implementation (^) By the appropriate health care team member(s), working together, utilizing the plan of care
Reassessment (^) When there is a significant change in the patient’s condition, diagnosis, and/or response to treatment Reprioritization (^) Based on changing patient needs even if the condition does not change
Communication (^) Via many avenues, including assessments, progress notes, shift report, referrals to other disciplines, case management discussions and patient care rounds Documentation (^) Interdisciplinary Plan of Care or Progress Note
The first time ANY individual writes on the patient’s chart, he/she MUST SIGN THE SIGNATURE PAGE, now located under a “sign me” tab on the patient’s chart, and provide signature, written name, contact information, and time and date of entry.
A majority of patients who have cardiopulmonary or respiratory arrest demonstrate clinical deterioration in advance. Early response to changes in a patient’s condition by specially trained individuals or Rapid Response Teams (RRTs) may reduce cardiopulmonary arrests and patient mortality. The hospital’s Rapid Response Team includes a Senior Resident, PICU RN, and Respiratory Therapist. As available, Nursing Supervisor is there to support team, but is not a member.
Who? Any member of the health care team concerned about a patient’s change in condition
Why? Acute changes in patient status
When? Criteria for Activation:
Activation is NOT required when changes in the patient’s condition are expected or are already being managed, such as in the operating room
How? Call extension 5555 - Provide your name, extension, patient name, unit, room number, and reason
When a patient or visitor medical emergency does occur, the individual finding the person in need of assistance should call extension 5555, or push the patient emergency button. Do not hang up from the command center until instructed to do so by them.
Take a moment to ask your manager if you are unsure.
The lock integrity, O2, suction, defibrillator and the first expiration date are checked:
Nemours’ recognizes the patient’s right to be free from restraints that are not medically necessary. All patients are treated with the least restrictive measures, consistent with their individual safety, and the safety of others in the environment. Refer to the Patient Care Restraint Policy 60.21 on the Nemours policy manager.
Prior to restraints initiation, alternative and preventative strategies must be attempted and documented. Alternative strategies may include, but are not limited to:
If less restrictive alternatives are ineffective in protecting the safety of the patient or others. Clinical justification and other requirements must be documented.
Clinical Leadership is informed every 24 hours of any patient who is in restraints for behavioral reasons for 12 consecutive hours or more or for multiple episodes totaling 12 hours or more. Clinical Leadership will facilitate problem solving regarding options/alternative strategies.
Restraints should be discontinued at the earliest possible time
Point of Care (Waived) Testing refers to a limited selection of laboratory tests performed outside the lab by frontline staff in the hospital or outpatient setting. Staff is required to complete specific training and demonstrate ongoing proficiency in performing POCT.
Examples are: Blood Sugar testing, Hem-occult testing, Urine pH. If you are unsure of what tests are performed in your area, please review with your manager.
GOAL: Effective and safe medication management
COMPONENTS INVOLVED: Planning Preparing & Dispensing Selection & Procurement Administration Storage Monitoring Ordering Evaluation
Authorized access to medication storage areas is limited to personnel involved in the dispensing, administration, and distribution of medications. All areas which have medication storage areas are responsible to ensure that only those who are authorized have access to these areas.
Special precautions need to be taken when storing, ordering and administering medications that have similar names or packaging to prevent potential medication incidents.
“NIS” folder “Wilmington” folder at LexiComp site, select “Indexes” select “Charts/Special Topics” 2nd from the bottom is “Look-Alike/Sound-Alike” information.
High alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error with these medications may be more devastating to patients.
Yes. High-risk medications must be double-checked by two nurses to visually and verbally verify the accuracy of the dose and route prior to administration. Both nurses must document on the patient’s chart. (Refer to policy 60.53.
The medication order is clarified with the prescriber before the order is carried out and a new order is written, if necessary.
No, each medication must be written out as a complete order.
Each order must be re-written after a transfer from one level of care to another or after a procedure requiring general anesthesia.
They are returned to the pharmacy to be credited to the patient account and/or destroyed by the pharmacy.
No. They must be stored (controlled) by the nursing staff.
An ADR is an unexpected, unintended, undesired, or excessive response to a drug that (meets at least one of the following nine criteria). ANY staff member or physician can report an ADR by calling extension 6ADR (6237) or by contacting the Pharmacy at extension 5702.
Refer to the Infection Control Manual on the NEMOURS Intranet Clinical Patient Care Sites Infection Control Manual found in the listing on the left hand side of the page.
Items that are contaminated with blood or other potentially infectious materials.
Printable isolation signs (airborne/contact/droplet precautions & c-difficile soap & water) are available on the Nemours Intranet via the following path: Clinical/Patient Care Sites/Infection Control/Printable Isolation Signs.
Be prepared to discuss how your patient care unit works to reduce health care-acquired infections for your patient population.
GOAL: Continually measure, assess and improve the quality of care, including patient health outcomes and service to patients and other customers.
COMPONENTS INVOLVED: Data Collection Performance Improvement (PI) Data Analysis Staffing Effectiveness
The organization has established a logical process to help associates see what can be improved and how. This model is called. SAFER. , which represents the following steps:
Select a performance measure. Involves identifying top priorities for improvement and planning who will be responsible for various performance improvement tasks. This step also involves designing new services or processes well.
Select
Analyze the data. Involves gathering data to see if a process is producing the desired results.
Analyze
Find an opportunity for improvement. Involves looking for possible causes of any problems and Find determining what processes need to be fixed or redesigned.
Execute actions. Involves putting improvements in place. This means actually changing how you Execute do things. It may involve testing a new procedure on a small scale first.
Reevaluate performance. Involves putting improvements in place. This means actually changing Reevaluate how you do things. It may involve testing a new procedure on a small scale first.
SAFER : AN EXAMPLE
S elect a performance
measure
What is the number of unsolicited patient complaints?
A nalyze the data
Where do the greatest numbers of complaints arise? There are a number of complaints related to wait times. Data reveals that Monday office visits are frequently overbooked.
F ind an opportunity for
improvement
Extend Monday’s office hours to accommodate the additional patient volume.
Execute actions Revise work schedules and let the patients know that you are changing hours.
R eevaluate performance Check to see if the number of complaints related to wait times decreased within a month of the change. Continue to monitor and take actions as appropriate.
No matter what your position, you play an important role in helping the organization improve performance and ultimately providing quality patient care.
The following are examples of how Associates participate in Performance Improvement:
One method is conducting a Failure Mode and Effects Analysis (FMEA). An FMEA is a team-based, systematic, and proactive approach for analyzing a high-risk process and identifying the ways the process can fail, why it might fail, and how it can be made safer. Its purpose is to prevent problems before they occur. Its focus is “something can go wrong and let’s fix it before it does,” rather than “nothing can go wrong.”
Our Past FMEAs: Medical Gas System, Chemotherapy, Mislabeled Specimens, Bar Coding, Patient flow throughout care continuum ED/Inpatient Our Most Recent FMEA: IV Medication Infusions
