Physician Joint Commission Compliance

IDENTIFICATION BADGE ALWAYS, ALWAYS wear your ID Your ID defines your role and access to certain systems and locations Keep key contact info with your ID

GENERAL DOCUMENTATION Handwriting is legible Sign, date and time all entries

Patient Involvement Encourage the active involvement of patients and their families in the patient’s own care as a patient safety strategy Educate patients and families on methods available to report concerns related to care, treatment, services and patient safety issues

History and Physical H&Ps are complete All patients must have a H&P within 24 hours of admission If an H&P is > 24 hrs but less than 30 days an interval update is acceptable Interval updates must address any and all significant changes – USE THE FORM If > 30 days must have new H&P

Pain Assessment Appropriate to the patient’s condition & treatment Includes: Nature Location Duration Severity Reassessment after intervention (nursing)

National Patient Safety Goal Medication Reconciliation On admission: MD List pre-admission medications on the first (white) page of med recon form; this serves as the medication section of the H&P Reconcile on the third (pink) page – state whether each home med will be continued or not continued Surgical patients admitted to hospital on day of surgery List pre-admission medications on med recon form in clinic Reconcile (pink page) at the time admit med orders are written (PACU) On admission: RN Review home meds with patient, alert MD of any discrepancy Verify the CPOE orders match the reconciled list, alert MD if not consistent

National Patient Safety Goal Medication Reconciliation On Discharge: MD provides instructions for discharge meds on first (white) page RN reviews med recon form and discharge Rx with patient Patient is given white copy of med recon form and pink copy of discharge Rx form

Medication Orders Requirements Write legibly (for non-CPOE) RNs and/or pharmacy must clarify the order, embrace requests for clarification PRN orders require a reason and range clarification Avoid therapeutic duplication of orders Distinguish between types of medication and when to use

Medication Orders Write your own orders Understand the limitation of NP and PA ordering privileges. RNs cannot write orders Verbal orders require RN to write the order RN to read back the order Provider must confirm the accuracy of read back Must be signed off within 48 hours; any physician of the treating team may sign off

Restraints Requires a reason which is behavioral Requires face-to-face evaluation by MD Must be time limited, never more than 24 hours Type of restraint should be specified Use CPOE restraint order set, assures compliance

Diagnostic Testing Requirements: Test, side/site, Clinical condition being studied Any specific instructions e.g. mammogram - palpable right breast mass

Informed Consent A discussion of risks and benefits as well as a signed consent is required Consent form promotes compliance Require date and time on the physician signature

Sedation & Anesthesia Moderate sedation requires a specific DOP (delineation of privileges) Minimum requirements: Assessment of heart and lungs Airway assessment Family/patient history of anesthesia/sedation complications Plan for Sedation/Anesthesia CRNA’s plan must be approved by anesthesiologist

Sedation Documentation Tool

Pre-Procedure Assessment

Universal Protocol (Site Marking) MUST be done for procedures with laterality, multiple structures, levels, even orifice with side MUST involve the patient, if possible MUST be unambiguous (no ‘x’, use initials) MUST be visible when prepped and draped DO NOT mark a non-operative site SHOULD be performed by the person performing the procedure

Universal Protocol (Time Out) Requirements Immediately prior to any surgery or invasive procedure Always includes procedure & patient ID Includes side/site and availability of diagnostic studies or special equipment (if applicable), including implantable items Includes bedside procedures, bronchoscopy, IR procedures

Safe Use of Medications Label all medications on and off the sterile field Drug name, strength & amount Normal saline (even in a basin) and contrast are medications Even if there’s only one medication in the field Many standard kits include pre-labeled syringes

Physician Documentation Post Procedure Requires post anesthesia or sedation note Brief post op note written, in addition to any dictated note Post op orders Medication reconciliation for same day and same day admit surgeries/procedures

National Patient Safety Goal Patient Identification Requirements Two patient identifiers prior to medication, blood, diagnostic study, procedure, treatment Patient Name – ask them to say their name, if conscious (don’t offer their name and wait for a ‘yes’) Medical Record # (DOB is the second choice in areas without arm bands) Confirm both prior to entering orders

National Patient Safety Goal Hand Offs Requirements Patient handoffs must contain standard elements, including: diagnosis, current condition, what to watch for in next interval of care Opportunity to clarify & ask question Contact information (pgr #) Update who to call

Document Critical Results If a nurse phones you with the critical test results (or Radiology or Laboratory call directly), repeat back the critical result to the caller. If you’re on the unit, document the result in the chart. Document what actions you took based on the critical result. When you document the critical result, date, time and sign your entry.

Infection Control Requirements No food/drink in the OR and in other patient care areas Limited use of papers and lap top computers Adherence to standard based and transmission precautions TB screening and Fit testing annually

National Patient Safety Goal Hand Hygiene Requirements Alcohol-based hand gel between patients Wash hands, soap and water, for at least 15 seconds when visibly soiled or caring for a patient on C.difficile precautions No artificial finger nails (includes tips and wraps) for direct caregivers; polish must be intact

National Patient Safety Goal Unacceptable Abbreviations DO NOT USE U IU QD QOD Trailing zero MS MgSO4 Requirements Spell out “units”, “daily”, “morphine sulfate”, etc. Use a leading zero (0.1 mg), but not a trailing zero (5 mg)

Suicide Risk Suicide is the #11 cause of death in the US (#3 in young people) Suicide in 24-hr facilities is the #1 sentinel event reported to Joint Commission We must Identify patients at risk for suicide Address immediate safety needs, provide for a safe environment Provide info (crisis hotline) to individuals and their families for crisis situations