Joint Commission Review Questions you may be asked

Upcoming Survey They are coming soon! Tracer Methodology - Surveyors may observe patient care, review patient records, and interview staff/patients/visitors JCAHO is officially TJC/“The Joint Commission” Focus patient safety and performance improvement. BE PREPARED! Be able to speak to ED Performance Improvement projects!

What performance Improvement (PI) projects have occurred? Improved Patient Flow Physician in Triage 7/2008-7/2013 Discontinued in 7/2013, along with fast tack Team system initiated 7/2013 Registration and triage in rooms when available. Urgent care rooms added 12/2013, resuming fast track patient flow. Improved lab turnaround times Electronic patient call in system Electronic tracking system Improved radiology reading and documentation times.

Additional Performance Improvement (PI) Initiatives ED Trigger system Vital sign standards identifying patients to be brought immediately into rooms and be seen by physician. Timeliness and Effectiveness Measures Core Measures Stroke Protocol-time to CT Acute MI-cath patency within 90 minutes Pneumonia-appropriate antibiotics within 6 hrs of arrival

Performance Improvement (PI) Projects Door to Balloon Time Goal: Burst page and STEMI worksheet to improve DTB time Result: Increased the percentage of patients who reach DTB < 90 minutes

Additional Performance Improvement Initiatives Moderate Sedation and Deep Sedation procedural reviews for compliance. Use of analgesics in long bone fractures. X-ray and EKG reviews for discrepancies. Trends for Unscheduled patient returns to the ED and patients leaving without being seen.

National Patient Safety Goals The National Patient Safety Goals (NPSGs) are key patient safety areas based on adverse event data. The NPSGs are areas of focus during the survey visit. Please be able to speak to them and demonstrate applications in your patient care.

Patient Identification Always use 2 unique identifiers Name Date of Birth/medical record number NOT room number or location.

How are critical lab values reported? Lab calls critical values to M.D. immediately Process… Write result down Read back to lab tech Wait for verification

When are Verbal Orders acceptable When are Verbal Orders acceptable? What is the process for verbal orders? Verbal orders only in EMERGENCY situation Process… R.N. writes order down R.N. reads back to M.D. M.D. verifies order R.N. signs as TORB with M.D. & R.N. name

Describe our process for medication reconciliation Medications entered into Chartmed by R.N. at triage Medications reviewed and verified by M.D. at evaluation Medication reconciliation needs to occur By time admission orders are written At discharge, provide an updated list with ED prescriptions. Reinforce the need for the patient to keep an accurate list of current meds.

Labeling Medications Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Includes syringes, medicine cups, and basins

When is patient pain assessed and re-assessed? Pain is first assessed at presentation It is re-assessed at least every 4 hours When interventions are provided such as pain control, ice, re-positioning pain is re-assessed A final assessment of pain is made at discharge or transfer to floor

Which patients do you assess for suicide risk? What is the process? Must be completed on ALL patients Done as part of nursing triage If concerned they use SAD PERSONS A patient found to be at risk is ordered for seclusion, placed on 1:1, and person and belongings searched

Prevent Infection Hand washing Reduction of foley catheter use. Universal precautions Contact and droplet precaution started in triage. Prevent blood stream infections

Hand Hygiene Clean hands before AND after every patient contact If hands are soiled use soap and water NO artificial nails

Describe the steps for “Universal Protocol” when doing an invasive procedure (NOT just “time out”) Pre-procedure verification Verify correct patient, procedure, & site Mark operative site Mark with initials or the word “yes” Do NOT use an “X” Must be visible after draping Conduct a “time out” Verify correct patient, side, site, procedure, position, & availability of proper equipment with informed consent.

What 3 conditions need to be met before restraining a patient? 3 conditions need to be met first… Only implement to protect patient or others Alternatives were tried and failed Least restrictive restraint must be used Order must be written within 1 hour Patient re-assessment every 1 hour Seclusion is a type of restraint Requires restraint form

Where can you find information about health care proxy / advance directives? Admitting asks if the patient has a health care proxy Social work can assist if patient wants to execute one Patients can refuse – must be documented Information can be found in meditech

Codes Red Fire Orange HAZMAT spills Black Bomb threat Pink Infant abduction Blue Cardiac arrest Triage Disaster activation Yellow Trauma Team Gray Crisis Team On back of red hospital card

Response to Fire R escue patient A larm – dial 22 C ontain fire Number for emergencies C ontain fire E xtinguish fire On back of red hospital card

Locate the Following Evacuation Plan Fire Extinguishers Fire Pulls Outside room 19 Fire Extinguishers Between room 12B & 14 Near housestaff room in radiology hall Near room 7B in ambulance hall Fire Pulls Near protection services Near ambulance bay

Who can turn off shut off valves for air/oxygen Who can turn off shut off valves for air/oxygen? Who can turn them back on? Charge nurse or attending can turn off RT turns back on Shut off Valves Types Oxygen, Medical air, Suction Location Room ENT-SH-1-6: Near ambulance entrance Room 7A-7B: Near 7A Room 8A-8B: Near 8B Room 9-19: Between PA desk and restroom

MAH Mission To improve the health of the residents of Cambridge and surrounding communities. Our services are delivered in a personable, convenient and compassionate manner, with respect for the dignity of our patients and their families. On back of red hospital card

Do Not Use Abbreviations Incorrect Correct U,u Units IU International units QD Daily QOD Every other day MS, MS04 Morphine MG, MGSO4 Magnesium Ug mcg Amps Medication and dose

Do Not Use No trailing zero Use leading zero Incorrect: Morphine 2.0mg IV Correct: Morphine 2mg IV Use leading zero Incorrect: Epinephrine .3 mg subcutaneous Correct: Epinephrine 0.3 mg subcutaneous Ranges for orders are NOT allowed! Morphine 2-4mg IV is NOT allowed!

Important Reminders ID badge at all times Date and time all orders Write legibly No food or drink in patient care areas Know location of two closest exits, evacuation map, fire alarm pulls, extinguishers, and oxygen shut off Speak about a PI project