Drs. , Ciubotaru, Stumacher, Adler, Menkel, Grantham

Joint Commission on Accreditation of Healthcare Organizations (JCAHO.org)

1.  Check all that apply.  All of the JCAHO requirements are based

    on the tri-partite mission of the JCAHO, which is to ensure that:

    [ ] Patient's rights are respected (note Bill of rights each floor)

    [ ] Quality care to patients is maintained (e.g., education)

    [ ] Safe care is provided to patients by a multidisciplinary team

        that assesses, coordinates, **communicates and follows up

     ** (There are currently 14 National Patient Safety Goals (NPSGs)
                            (15 NPSGs for 2007)

2.  Check all that apply.  Unannounced surveyors from JCAHO visit patient

    care areas to see that students and residents:

    [ ] Wear ID badges and identify themselves to patients

    [ ] Wear gloves, but only in patient rooms

    [ ] Wash hands after removing gloves

    [ ] Follow all isolation protocols

    [ ] Know who supervises whom (Chain of Command)

    [ ] Know how to reach the Attending (Captain of the ship) and

        discuss important diagnostic and therapeutic issues with the

        attending (including procedures)

    [ ] Notify the attending if there is any significant change in

        patient status or an 'unanticipated patient outcome'

        [adverse event], so that the family can be notified

    [ ] Know what they are allowed to do and not do

    [ ] Can provide documentation to nurses or surveyors the procedures

        they are permitted (credentialed) to perform on their own (BPF)

    [ ] Know and follow chaperone rules

    [ ] Provide verbal and written informed consent prior to procedures

        including risks, benefits, alternatives

    [ ] Utilize at least two "identifiers" for patients (but not room)

    [ ] Incorporate 'time out' and extra verification for procedures

        that are on Left or Right (e.g., thoracentesis, arthrocentesis)

        (active verification of: 'the correct patient, the correct

        procedure, the correct site')

        STAR: Stop (to focus), Think, Act, Review (for desired result)

    [ ] Assess patient discomfort, including nausea, dyspnea and

        pain ("the 5th vital signs")

    [ ] Maintain computer confidentiality (screen off when not in use,

        screen not aimed at public hallway)

    [ ] Know how to write a 'PRN' order for medication

    [ ] Know not to write a 'PRN' order for restraints

    [ ] Document strategies used to reduce need for restraints

        including verbal de-escalation, empathetic listening,

        voluntary time-out in a quiet & less stimulating environment,

        re-focus of patient's attention, clear instructions to the

        patient regarding consequences of his behavior, and when

        possible, a "behavioral advance directive"

    [ ] Know that for Medical/Surgical 'safety' Restraints,

        the order must be time limited to no more than 24 hours

    [ ] Know that for Behavioral 'psychiatric' Restraints, the physician

        must see the patient within 1/2 hour of ordering the restraint,

        & that for adults, the order can last for no more than 4 hours

    [ ] Complete charts legibly, in a timely fashion with

        advance directives, health care proxy, pap/pelvic, smoking

        cessation.   No blank areas.  No unapproved abbreviations

        (e.g., no 'AA', 'cc', 'u', 'QD', 'QOD')

    [ ] Ensure that information regarding 'DNR' status documents an

        appropriate discussion with the patient and/or family

        about an irreversible condition (& DNR orders must be signed

        by an attending)

    [ ] Include up to date 'problem lists' and 'medication lists'

        particularly when transitioning patients to other areas of

        the hospital.  E.g, when a patient is transferred from Detox

        to Medicine for asthma, don't lose "withdrawal" from the

        problem list. JCAHO 'tracer' methodology is used to detect

        absent or inaccurate medication lists during such transfers

        of care (see 'handoffs', below)

3.  Check all that apply.  In case of an emergency, JCAHO wants to

    ensure that students and residents:

    [ ] Know that if you SMELL smoke, call Security (x4444):

    [ ] Know if you SEE smoke or fire, follow RACE protocol:

        Rescue people in immediate danger

        Alarm via fire alarm box (and x4444)

        Confine fire by closing all doors and windows

         (but check for flashing smoke detector lights in patient rooms

         before closing doors)

        Evacuate patients (initial move is lateral)

        Extinguish fire by using extinguishers (P.A.S.S.)

    [ ] Know where the alarms and fire extinguishers for the area

        in which you work are located (& O2 shut-off valve)

    [ ] Know hospital CODES: (Red, Blue, Pink, D)

    [ ] Know how to respond to DISASTER and other codes.

    [ ] Know the "Bell Code" for the area of hospital to which they

        are assigned:______________

4.  JCAHO wants students and residents to participate in performance

    improvement activities and measures of quality of care such as:

    [ ] Community Acquired Pneumonia (CAP)

    [ ] Acute Myocardial Infarction (AMI)

    [ ] Congestive Heart Failure (CHF)

    [ ] DVT prophylaxis

    [ ] peri-operative beta blockers

    [ ] **communicating better with consultants by making it clear

        how consultant is contacted, how urgent the consultation is,

        why consultation is needed, and acknowledgment that

        consultant's note has been read

    [ ] **better "handoffs" of patients to other teams:  e.g.,

        from day to night, week day to weekend, transfer from

        ER to floor, floor to ICU, hospital to PCP.  In part

        accomplished by better tracking of problem lists,

        medication lists, and better transfer/discharge notes.

    For more information, can contact:

    Administration: Debra Kramer

    Nursing: Pat Murphy

    QA: Jorgi or Lulu                         jh: 10-2005