Joint Commission Update

Clinical Compliance and Risk ManagementFall 2012

Overview

BWH Survey Activity

Hot Topics/Risk Areas

Departmental Education Plan

BWH Survey Activity

TJC: Hospital-wide - Window is open till

February 5, 2013

CMS: CMS Validation post TJC – up to 6 months

Survey Plan

Notification Plan

Command Center

Observations, Interview and Medical Record Review

Surveyor Interaction – Quality and Patient Safety

HOT TOPICS

Infection Control (sterilization, disinfection, PPE) National Patient Safety Goals Medical Record Documentation (date & time every

entry, completeness) Restraints Interdisciplinary Care and Continuity Hand- Off Communication

Infection Prevention and Control

Are staff following the signs and using PPE? Cross Contamination How is a patient’s precaution status

communicated? Hand Hygiene Clean – Dirty Segregation/ CDS – cleaning,

disinfection, sterilization (Manufacturing Directions for Use)

National Patient Safety Goals

Patient Identification Reporting of Critical Test Results Medication Safety

• Anticoagulation

• Medication Reconciliation

• Labeling Universal Protocol Suicide Assessment Infection Prevention and Control

• MDRO, SSI, CLABSI and new CA-UTI

Documentation

All entries dated, timed, signed, and legible Brief operative and procedural notes History and Physical Reassessment just prior to anesthesia induction Informed Consents complete Progress Notes daily No inconsistencies with Allergy information between

disciplines Advance Care Directives/End of Life Discussions

Interdisciplinary Care and Communication

Rounds

Continuity/Consistency

Communication

Hand-offs

Medical Staff Credentialing and Privileging - OPPE/FPPE 6 General Areas of competencies:

• Patient care, medical-clinical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism and systems- based practice.

Ongoing Professional Practice Evaluation- requires ongoing review of criteria, provides closer oversight and fosters a more evidence based privilege renewal process

Focused Professional Practice Evaluation-specific focus on practitioners performance new or based on potential practice issues

What’s New

Patient Visitation Rights - The hospital allows for the presence of a support individual of the patient’s choosing.

New National Patient Safety Goal - Implement evidence based practices to prevent indwelling Catheter Associated-UTI (CAUTI)

Implement evidence based practices to prevent indwelling Catheter Associated-UTI (CAUTI)

ED Order Entry – established guidelines BICS – prompts for removals

Discontinue urinary catheters as soon as possible BWH CAUTI guidelines located on Pike Notes on the

infection control page in “policies”

Restraints

MD order obtained prior to application MD documentation of daily assessment MD documentation of one hour face to

face on behavioral/violent pt. restraints

Restraint Education Restraint Death Reporting

Life Safety and Environment of Care

Clutter Clear exits No food or drink in patient care areas

CODE RED - Alarm (pull stations-2-6555), Rescue, Contain, Evacuate

Additional Resources

Pocket Booklets/Continual Readiness Page from Pike Notes

http://www.bwhpikenotes.org/Employee_Resources/Compliance/readinesscentral.aspx

Email Communication at Survey Time