TJC has come and gone!

How did we do?

Great! This is fabulous news!!! Kathy/JCR

Accreditation Based on Impact on Patient Care 4 14

Our Action Plan Direct Impact – 45 days (1/28) Indirect Impact – 60 days (2/12) Measures of Success – 4 months (April 2010)

4 Direct Impact Life Safety – hallway Provision of Care – medication instruction Record of Care – post-op note Waived Testing – Accucheck test strip containers

14 Indirect Impact Environment of Care – 2 Life Safety – 3 Human Resources – 1 Medication Management – 3 Medical Staff – 2 Record of Care – 2 National Patient Safety Goals - 1

Environment of Care Testing water flow devices Documentation of drain testing Testing of fire extinguishers in construction areas Testing operation of rolling fire shutters Battery operated light required in transfer switch location

Life Safety Wall penetrations Opening in sheet rock in construction staging area Labeling of “K” extinguishers

Human Resources Primary source verification

Medication Management Include Heparin in high risk drug policy Range orders (review of order sets) Incomplete medication order

National Patient Safety Goals Analysis of fall reduction data

Medical Staff Ongoing Professional Practice Evaluation Focused Professional Practice

Record of Care Physician signing verbal orders within 48 hours Date and Time required on ALL chart entries

TJC will be back. Constant readiness, Taking appropriate care of the next patient will take care of the next survey!