1. Department of Quality and Regulatory Affairs Barbara Ann Karmanos Cancer Center The Karmanos Cancer Center Regulatory Readiness (for Non Clinical Staff) 2012

2. Regulatory Readiness Karmanos Cancer Center (KCC) is committed to delivering high quality care. KCC is committed to keeping our patients safe. KCC maintains a constant state of readiness for any regulatory survey that may occur. Each staff member plays an important role in helping KCC achieve and maintain this constant state of readiness. KCC Patients and families may contact The Joint Commission regarding quality concerns.

3. The Joint Commission can conduct an unannounced survey at any time. The survey team will use a process called “tracer methodology” to follow patients through hospital processes. Surveyors will look at the care, treatments and services provided by individual departments, as well as how we work together. The Joint Commission National Patient Safety Goals are required standards of care that protect patient safety and are part of patient care daily routines Regulatory Readiness

4. Tracer Methodology: What is it? Tracer Methodology follows (traces) a patient through their hospital stay –Surveyors may start a “tracer” at any point of a patient’s stay. Tracer Methodology surveys from a patient perspective –Surveyors will speak with patients Tracer Methodology evaluates patient care and safety at the bedside –Surveyors will ask staff questions regarding: How they deliver safe care What their processes and policies are, How do the staff know if they are doing a good job?

5. How can you get ready now? Stay updated on your department’s or unit’s policies Stay updated on your department’s or unit’s process improvement initiatives Know the common items: (refer to your badge card) –Memorize how to respond to a fire: R.A.C.E. and P.A.S.S. –The emergency codes –The KCC mission statement –The National Patient Safety Goals

6. Regulatory Readiness 2012 National Patient Safety Goals (NPSG): –Defined by the Joint Commission to help accredited organizations address specific areas of concern regarding patient safety. –Each goal has recommendations –Each year the goals and recommendations are re-evaluated, re-prioritized and modified

7. Use at least two patient identifiers when –Providing any treatments or procedures –Identifying a patient in any way (transporting, calling back from a waiting room, etc…..) Patient identifiers –Can be a patient name, MR number, or date of birth –Never a room number 2012 NPSG “Identify Patients Correctly”

8. Report results of critical tests & diagnostic procedures on a timely basis –Results of critical tests are reported to authorized clinical staff 2011 NPSG “Improve Staff Communication”

9. Label all medications, medication containers and other solutions on and off the sterile field in peri-operative and other procedural settings. 2012 NPSG “Use Medicines Safely”

10. Maintain and communicate accurate patient medication information. –Obtain a list of all medications that a patient is currently taking when they are admitted. –Compare the list of medications that the patient was taking on admission with the medications ordered while in the hospital. Resolve all discrepancies. –Provide the patient or family with an accurate list of all medications that they should be taking when discharged. –Explain the importance of managing their medication information to the patient or their family. 2012 NPSG “Use Medicines Safely”

11. Comply with hand hygiene guidelines. –WASH YOUR HANDS with soap and water for 15 seconds or use alcohol hand gel upon entering and exiting a patients room and after use of gloves –KCC monitors compliance with hand hygiene through direct observation. Implement evidenced-based practices to prevent infections due to multi-drug resistant organisms (MDRO). –Follow policies and practices aimed at reducing the risk of transmitting MDROs. 2012 NPSG “Prevent infections”

12. Universal Protocol applies to all operative and other invasive procedures that expose patients to more than a minimal risk. These include procedures done in settings other than the operating room such as in the Infusion Center, Ambulatory Clinics, Radiation Oncology Center, and in Patient Rooms. The Universal Protocol includes: –Pre-procedure verification of correct patient, correct procedure, correct site/side, needed implants / medications. –Site marking as appropriate. –“Time-out” immediately before starting the procedure to re-verify correct patient, correct procedure, correct site/side, implants and medications. 2012 “Prevent Mistakes in Surgery”

13. Are You Ready? For each National Patient Safety Goal: –ask yourself what the hospital process is, and how well is your unit or department doing? Always wear your hospital ID badge Be aware surveyors may stop to talk to you any time during a survey. Be proud of your job and your role in providing safe, high quality patient care. Know your department’s “process improvement initiatives” and where to find your PI results Know how to find KCC policies and refer to them if needed.

14. Regulatory Talking Tips! Always Be positive in your response to questions Make eye contact and be professional Respond by referring to KCC policies for processes…. e.g. “Our process is……” “Our policy states we …..” Tell the surveyor what you know and then refer them to the correct person when unsure of information Just answer the question asked….. Use your department resources to answer surveyor’s questions. –For example, use reference binders, “Survey Readiness Guide” or process improvement bulletin board (if your department has one).

15. Regulatory Talking Tips! Don’t be negative in your response Don’t respond by saying “This is how I do it…others may do it differently” or “We always do it this way….” Don’t wait to get ready: Be prepared early and use your resources. Don’t worry! Respond professionally and prepare early.

16. Regulatory Readiness Summary Karmanos Cancer Center (KCC) is committed to delivering high quality care. KCC keeps our patients safe In order to succeed in delivering high quality care, KCC maintains a constant state of readiness for any regulatory survey that may occur. Each staff member plays an important role in helping KCC achieve and maintain this constant state of readiness. Joint Commission National Patient Safety Goals are part of the constant state of readiness in which staff must incorporate into their daily routine.

17. Summary We hope this Computer Based Learning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented. Click the Take Test button on the left side when you are ready to complete the requirements for this course. Click on the My Records button to return to your CBL Courses to Complete list. Click the Exit button on the left to close the Student Interface.