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Preparing for the JCIA Consultation Survey

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What will be presented

AUBMC Accreditation timeline How JCIA standards are spelled out How to get ready for the

consultation survey What you need to know International Patient Safety Goals

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AUBMC Accreditation Timeline

J an 2007 Oct 2007

Feb 2007 Mar 2007 Apr 2007 May 2007 J un 2007 J ul 2007 Aug 2007 Sep 2007

Today2007

Actual JCIA Accreditation Survey period starts

Apr 16, 2007JCIA Consultation Survey

JCIA Consultation Survey April 16 – 20th 2007

Depending on the survey findings, and after a 6 months notification period, the actual JCIA survey can be conducted

MOPH Accreditation visit is due in May 2007

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How JCIA standards are spelled out

PFR.9.4 Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures.

Intent of PFR.9.4

When the planned care includes surgical or invasive procedures, anesthesia, use of blood and blood products, or other high-risk treatments or procedures, a separate consent is obtained. This consent process provides the information identified in PFR.9.1 and documents the identity of the individual providing the information. Measurable Elements of PFR.9.4 1. Consent is obtained before surgical or invasive procedures. 2. Consent is obtained before anesthesia. 3. Consent is obtained before the use of blood and blood products. 4. Consent is obtained before other high-risk procedures and treatments. 5. The identity of the individual providing the information to the patient and

family is noted in the patient’s record.

Statement of the standard

Intent

Measurable Elements

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How to get ready for the consultation survey

AUBMC Mission Statement AUBMC policies & procedures

manual Departmental policies &

procedures manual AUBMC Safety/Emergency

Plans ● Safety plan● Security plan● Hazardous material & waste

management plan● Emergency response plan● Fire safety plan● Medication equipment plan● Utility systems plan● Infection control manual

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Access & Continuity of Patient Care:

Admission of patients (ACC-MUL-001) Discharge of patients (ACC-MUL-002) Transfer of patients (ACC-MUL-003) Access to and sharing of Information

about the patient’s care among all staff providing care to patients Multidisciplinary Assessment and Reassessment of Patients (AOP-CLN-001)

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Patient and Family Rights

• Patient & family are informed of Patient Bill of Rights and participation in care process.

Patient handbook &posters around AUBMC

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Patient and Family Rights (cont’d)

• Confidentiality of information, security and privacy of patient. Confidentiality, Security, Privacy & Release of Patient Information (MOI-

MUL-002)

Confidentiality Guidelines:• Do not allow medical information on computer terminals to be

visible to patients or other individuals not directly involved in the patients’ care.

• Exercise care when disposing of medical information. • Do not place medical records or other medical information

where they can be easily accessed or removed by unauthorized persons.

• Speak softly over the phone and try to avoid excessive use of the patient’s name.

• Do not discuss patient information with anyone in a social conversation.

• Exercise privacy when addressing patients.• Do not discuss the reason for the patient’s visit in the waiting

area or in the presence of others.• Do not disclose results of tests to individuals not directly

involved in the patients’ care. • Do not reveal to unauthorized persons that a patient is, has

been, or will be admitted to AUBMC.

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Patient and Family Rights (cont’d)

Guidelines on Handling of Complaints at AUBMC

1. Try to resolve the complaint, if unresolved2. Refer to the chairperson/department head3. Nursing - related complaints - Director For

Nursing Services3. Safety - Safety Officer4. Others - Patient's Relations Office

Patient-care Complaints - Medical Center Director/AUBMC Risk Manager

Complaints & Complements Guidelines (GLD-ADM-003)

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Patient and Family Rights (cont’d)

Informed consent: • Obtain informed consent for special

procedures (list identified).• Inform patient/family/guardian, in a

language/format that is understood, about proposed treatment for care decisions.

• Document signature of patient/family/guardian on informed consent and specify name of guardian.

Patient Consent (PFR-MUL-001)

Mission Statement: AUBMC website & posted within AUBMC

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Quality Improvement and Patient Safety

• PDCA Model, indicators, all staff participation

PI Plan (QPS-MUL-002).• Incident reporting, monitoring of errors. Patient-Related Risk Management Plan (QPS-MUL-

001)

Prevention and Control of Infection

Hand Hygiene The hospital wide PCI Manual is still under

development by the Infection Control Program.

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Governance Leadership and Direction

Subject Page number

1. Department mission statement (optional)

2. Scope of services and hours of operation

3. Organization structure (represented in an organization chart and authority matrix)

4. Physical facilities (including physical layout and major equipment)

5. Safety and infection control procedures (in coordination with the Occupational Safety Officer and the Infection Control Program)

6. Internal performance improvement plan (selection and monitoring of indicators)

7. Departmental orientation program

8. Internal (operating) policies and procedures

Departmental Policy and Procedure Manual, know the content

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Safety Plans

Fire Safety plan No smoking policy within AUBMC

Smoking Policy Preparing, testing and responding to

disasters Disaster plan Hazardous materials inventory, handling,

storage, use and the control and disposal of hazardous materials and waste.

● Handling spills in your workplace hazardous materials

Regular staff education, training and documentation regarding safety plans

Training, testing & documentation of staff who operate & maintain medical & utility equipment

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Facility Management and Safety (manual under construction)

• Fire safety: RACE, PASS, 5555• Disaster plan: 9999, participation in

drills• Security: safegaurd children and

vulnerable patients.• Equipment management: training

on new equipment, ensure functionality before patient use.

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Staff Qualifications& Education

• Job description: Each staff member’s responsibilities are defined.

HR Policy & Procedure Manual, Competency Management (SQE-HRD-001)

• Staff evaluation according to job description: Performance appraisal process done yearly.

Orientation Plan (SQE-HRD-004), Performance Appraisal Policy (under development)

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Patient Medical Record

Records and information are protected from loss, destruction, tampering, and unauthorized access or use.

Health care providers have access to the information in a patient’s clinical record each time the patient is seen for a new or continuing care episode.

Medical Record Content and Documentation (MOI-MUL-003)

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2007 International Patient Safety Goals

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2007 International Patient Safety Goals Poster

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Goal #1: Identify Patients Correctly

Patient Identification Policy

COP-MUL-009

Patient room number should not be used for patient identification.

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Goal #2: Improve Effective Communication

Verbal orders have to be “read back” by the receiver to check for accuracy.

Other communication methods used in AUBMC include:

Inter-shift report by nursing staff. On-service/off-service notes in

the Multidisciplinary Notes. Hand over report between house

staff. Multidisciplinary morning rounds.

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Goal #3: Improve the Safety of High-Alert Medications

Nursing & Pharmacy

Committee is working on the list of high alert

medications.

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Goal #4: Eliminate Wrong-Site, Wrong-Patient, Wrong-

Procedure SurgeryPre-operative/Pre-procedure

Verification Form: First Verification is performed by

the nurse before pre-medication. Second Verification is performed

by the nurse before the procedure. Third Verification, “TIME OUT”, is

performed just before starting the procedure.

“TIME OUT”: the nurse initiates the process, the surgeon and anesthetist verify the correct patient name, procedure and site.

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Goal #5: Reduce the Risk of Health Care-Associated

InfectionsAll AUBMC Personnel shall use

proper hand hygiene before:● Patient contact ● Applying gloves before

starting any patient related procedure such as: central- venous catheters (CVC), inserting urinary catheters, peripheral vascular catheters, or other invasive devices that do not require surgery

● Eating, drinking, preparing or handling food

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Goal #6: Reduce the Risk of Patient Harm Resulting From

Falls

Fall Risk Assessment Tool: initiated upon admission, then weekly and as condition evolves, for adults.

According to the findings, the patient is categorized as “at Risk” or “No Risk”.

If patient is at risk of fall, the patient is put on fall risk precaution.

In pediatric population, fall precaution is done daily.