Preparing for the JCIA Consultation Survey

1
Preparing for the JCIA Consultation Survey
2
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

3
AUBMC Accreditation Timeline

• 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

4
How JCIA standards are spelled out
Statement of the standard
Intent
Measurable Elements
5
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

6
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
  patients care among all staff providing care to
  patients ? Multidisciplinary Assessment and
  Reassessment of Patients (AOP-CLN-001)

7
Patient and Family Rights

• Patient family are informed of Patient Bill of
  Rights and participation in care process.
• ? ? Patient handbook posters around AUBMC

8
Patient and Family Rights (contd)

• 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 patients name.
• Do not discuss patient information with anyone in
  a social conversation.
• Exercise privacy when addressing patients.
• Do not discuss the reason for the patients 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.

9
Patient and Family Rights (contd)

• Guidelines on Handling of Complaints at AUBMC
• 1. Try to resolve the complaint, if unresolved
• 2. Refer to the chairperson/department head
• 3. Nursing - related complaints - Director For
  Nursing Services
• 3. Safety - Safety Officer
• 4. Others - Patient's Relations Office
• Patient-care Complaints - Medical Center
  Director/AUBMC Risk Manager
• ? Complaints Complements Guidelines
  (GLD-ADM-003)

10
Patient and Family Rights (contd)

• 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

11

• 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.

12
Governance Leadership and Direction
Departmental Policy and Procedure Manual, know
the content
13
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

14
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.

15
Staff Qualifications Education

• Job description Each staff members
  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)

16
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 patients clinical record each
  time the patient is seen for a new or continuing
  care episode.
• ? Medical Record Content and Documentation
  (MOI-MUL-003)

17
2007 International Patient Safety Goals
18
2007 International Patient Safety Goals Poster
19
(No Transcript)
20
Goal 1 Identify Patients Correctly
Patient room number should not be used for
patient identification.

• Patient Identification Policy
• COP-MUL-009

21
(No Transcript)
22
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.

23
(No Transcript)
24
Goal 3 Improve the Safety of High-Alert
Medications

• Nursing Pharmacy Committee is working on the
  list of high alert medications.

25
(No Transcript)
26
Goal 4 Eliminate Wrong-Site, Wrong-Patient,
Wrong-Procedure Surgery

• Pre-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.

27
(No Transcript)
28
Goal 5 Reduce the Risk of Health
Care-Associated Infections

• All 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

29
(No Transcript)
30
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.