JCAHO UPDATE June 2005

The Bureau of Primary Health Care is continuing to encourage Community Health Centers to be JCAHO accredited. JCAHO’s new focus is on continuous compliance.

Survey Changes for 2006 Unannounced surveys –at an unscheduled date Tracer Methodology: traces the care experience that a patient has while at the clinic

Tracer Methodology: Patients are selected by type of visit or use of cross services (i.e. medical and behavioral health or dental) or as related to topics such as medication management or infection control.

Tracer Methodology: Surveyors observe and/or discuss with staff: Flow, management of risk points and communications Strengths in processes and opportunities for improvement Issues requiring additional attention Baseline assessment

Tracer Methodology Surveyors look at the following at each contact point: Use of Data Infection Control Medication Management Role of staff: care for patients, ability to provide patient lists, etc.

Survey 2006 Shift from making high score to showing evidence of maintaining safe, high quality systems If any Requirements for Improvement, GCHD will submit an “Evidence of Standards Compliance Report” within 45 days.

Most Challenging Standards for Community Health Centers in 2004 A process for ensuring the competence of all practitioners Qualified individuals are granted clinical privileges

Continued... Contractual services provided safely and effectively. Leaders develop, implement, monitor policies and procedures for care, treatment and services The organization conducts hazards vulnerability analysis, etc.

Continued... The organization monitors the environment (annual evaluation of plans for safety, security, fire safety, utilities, hazardous materials, medical equipment, emergency planning) The organization establishes standards for abbreviations, acronyms and symbols as well as list of those not to use.

Continued... The medical record contains a summary list of all significant diagnoses, procedures, drug allergies and medications. The organization provides access to all relevant patient medical records for use in patient care, treatment and services.

Continued... Pain is assessed and documented for patients when warranted by the patient’s condition. The organization uses at least two patient identifiers whenever taking blood samples or administering medication Documentation that the patient receives education and training specific to their needs and as appropriate to the care and services.

Continued... Quality control checks, as defined by the organization, are conducted on each lab procedure Medications are properly and safely stored

Continued... Once the organization has prioritized its goals for preventing health-care acquired infections, strategies are implemented to achieve those goals (i.e. hand hygiene program).

More JCAHO Priorities for 2006 Use of current clinical guidelines – how are they selected, updated, evaluated Integrating and coordinating services – i.e. communication with the pharmacy on patient-significant data, coordinating services in the clinic and in the community

Improving safety performance – there is a culture of safety/performance improvement, there are resources for staff and support, sentinel events are managed How we use patient satisfaction data to improve services Performance Improvement clinical monitors: process and outcomes – the PI plan is effective

Focus on National Patient Safety Goals Goal 1 Improve the accuracy of patient identification Goal 2 Improve the effectiveness of communications among caregivers Use a “time out” to verify correct patient, correct procedure, and correct body part during each procedure

Goal 3 Improve the safety of using medications. Goal 7 Reduce the risk of health care- associated infections by adhering to OSHA and CDC guidance. Goal 8 Accurately and completely reconcile medications across the continuum of care.

Staying Ready for JCAHO Use survey self-preparation tools Identify changes in standards, priorities Use analysis tools to identify organization risk points Train and cross-train staff