1. Joint Commission Review
Questions you may be asked

2. 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!

3. 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.

4. 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

5. 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

6. 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.

7. 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.

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

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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

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

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

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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!

27. 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