Few Things to Know and Remember for Joint Commission Survey

Few things to remember for Joint Commission Survey

Hospital Vision/Mission:

AIDET

Acknowledge

Introduce

Duration

Explanation

Thank You

Start discussing something, even if you don’t know the specific answer. Buzzwords: Patient Care, Quality, and Safety.

1. National Patient Safety Goals. Start with two patient identifiers.

Goal 1 / Improve the accuracy of patient identification.
1A / Use at least two patient identifiers when providing care, treatment or services.
Goal 2 / Improve the effectiveness of communication among caregivers. Remember Read Back, SBAR, and Hand Offs.
Goal 3 / Improve the safety of using medications. Remember look-alike/sound-alike drugs, labeling of all meds. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
Goal 7 / Reduce the risk of health care-associated infections. Hand Washing.
Goal 8 / Accurately and completely reconcile medications across the continuum of care.
Goal 9 / Reduce the risk of patient harm resulting from falls.
Goal 13 / Encourage patients’ active involvement in their own care as a patient safety strategy. SPEAK UP
Goal 15 / The organization identifies safety risks inherent in its patient population.
15A / The organization identifies patients at risk for suicide. It is applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
Goal 16 / Improve recognition and response to changes in a patient’s condition. RRT.

2. DO NOT USE ABBREVIATIONS LIST

U, IU, QD, QOD, TRAILING ZERO (X.0 mg), LACK OF LEADING ZERO (.X mg), MS, MSO4, and MgSO4

3. Sentinel Events

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or risk thereof. Examples: Abduction of any patient receiving care, unanticipated death of a full-term infant, hemolytic transfusion reaction due to blood group incompatibility, wrong patient

4. Root Cause Analysis (RCA)

It is a process for identifying the basic or causal factors that cause an occurrence, incident (sentinel event), or variance in performance.

5. Fire Safety:

R-rescue A- alarm C- confine E- evacuation

6. FEMA (Failure Mode Effects Analysis): Proactive program that conducts proactive analysis to reduce risks to patients, staff, and visitors. Most recent: Prevention of errors associated with anticoagulation use.

7. PI activities of Dept.

SBAR - Situation - Background - Assessment - Recommendation

PDSA - Plan - Do - Study - Act

Quality Improvement Techniques:

1) 2 patient identifiers

2) Read Back

3) "I understand"

4) Medication and Problem List Reconcialiation

5) PI projects - unitwide is timely discharge

- hospitalwide is preventing venous thrombosis

Miscellaneous:

sentinel event - any event that has a significant impact on patient care

- triggers a root cause analysis

i.e. kernicterus/death from hosp infx/disruptive behavior

Fire Code - 4 number code located on top of the fire switch

Code yellow – infant abduction

Code Amber – fire

PICO Approach to Questions:

P roblem

I ntervention

C omparison

O utcome