1. Joint Commission Readiness
Riley Lunch and Learn
Michele Saysana, MD
August 18, 2010

2. The Joint Commission (TJC)
Formerly know as JACHO
Accredits health care organizations based on quality and safety standards
Findings are made public

3. How do they evaluate us? 12-14 surveyors, 1 week, every 3 years
IU, Riley, and Methodist
Tracer Methodology
Follow a patient through the system
Nursing, Physicians, Environment of Care, Pharmacy, Human Resources

4. Quick Tips Be polite Do NOT run from a surveyor Use your resources
Little red book
Emergency Reference Info tag
2010 National Patient Safety Goals

5. Orders ALL orders need to have PRN orders must have a indication Date
Time
Legible name
Dictation number
PRN orders must have a indication
Pain, fever, etc.

6. Verbal Orders All verbal orders MUST be signed within 48 hours
We are at ~80% compliance
Sign in Cerner on Orders tab

10. Fast Facts What do you do if there is a fire in the hallway right now?
Rescue Activate Contain Evacuate
Pull the pin Aim Squeeze Sweep

11. Culture of Safety Survey
Strengths
Teamwork
Leadership expectations and actions promote safety
Areas for improvement
Handoffs and transitions
Feedback and communication about error

12. Medications All syringes must be labeled
Drug
Concentration
Amount in the syringe
Exception – if you are giving the medication as soon as you draw it up

13. Culture of Safety Survey
Annual, nationwide survey
Identifies hospital employees and medical staff perception of safety
Riley’s overall grade 81%
Best of IU/RI/MH

14. Fast Facts
Who do you ask to be paged if you need security called? (i.e. the codename)
Dr. Armstrong

15. OPPE Ongoing Professional Practice Evaluation
Monitoring of Medical Staff performance in relation to measures identified by each service
Coordinated by Clarian Medical Staff Office

16. FPPE Focused Professional Practice Evaluation
New medical staff members
Existing members granted new privileges
If identified trends in OPPE
Review based on service/specialty
Coordinated by Clarian Medical Staff Office

17. Where should your ID badge hang?
Fast Facts
Where should your ID badge hang?
Above the waist

18. Performance Improvement
PI = QI = CQI = Quality Improvement
TJC uses PI to refer to performance improvement

19. So what are our Riley PI projects?
Hand Hygiene
Handoffs/Transitions
Nurse bedside report
Resident Handoffs
CaBSI – Catheter associated blood stream infections

20. So what are our Riley PI projects?
Asthma Action Plans
100% compliance at Riley
ID Bands – improving the rate of proper patient identification
Decreased the error rate from 18% to 5%

21. Fast Facts What are 3 ways to promote patient confidentiality?
Do NOT discuss patients in public
No names on white boards
Log off Cerner, Careweb, Synapse when not in use

22. Infection Control Wash hands when entering and exiting rooms
Follow directions on isolation signs
Wear PPE when exposed to bodily fluids
Clean stethoscope between patients

23. Consent All procedural consents MUST include: Procedure
Name of Treating Practitioner
Patient’s name either printed or labeled on the consent
Patient or patient’s representative sign, date, & time consent
Treating practitioner’s signature and date

24. Universal Protocol
Procedural site labeling – including laterality must be performed.
Procedural Time Outs
Stop activity
Focus on the TIME OUT
OR, bedside, treatment room, ED
Completed Consent MUST be on chart

25. Code Blue – medical emergency Code Adam – infant/child abduction
Fast Facts
Name the 3 Disaster Codes
Code Blue – medical emergency
Code Red – fire
Code Adam – infant/child abduction

26. Post-Anesthesia Evaluation
After the patient has the opportunity to recover from anesthesia
Within 48 hours of the procedure ending
MUST be documented in the medical record

27. Operative Note
Immediate post-procedure note MUST be documented following all procedures and include:
Names of the primary surgeon and assistants
Preoperative and postoperative diagnosis
Technical details of procedure
EBL
Specimens removed
Description of findings
Condition of the patient at the end of the procedure
Dictated operative notes MUST be completed within 48 hours of the procedure

28. Restraint Orders
The Joint Commission and CMS have very specific guidelines for restraint use.
Restraint Orders
Cannot have a start and stop time per day.
Cannot have a “trial off” period.
Need new order each and every time a restraint is restarted.
Continual use of restraints needs to have a daily restraint order.

29. Name 2 National Patient Safety Goals
Fast Facts – Last One!
Name 2 National Patient Safety Goals

30. Fast Facts – Last One! Improve accuracy of patient identification
Improve communication among caregivers
Improve safety of medication use
Reduce risk of healthcare associated infections
Accurate medication reconciliation
The organization identifies safety risks
Universal Protocol to prevent wrong site/wrong procedure/wrong patient surgery