[This is the original 'short' version.]
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) sends unannounced surveyors to hospitals to make certain that
QUALITY OF CARE is being provided to patients, that PATIENT'S
RIGHTS are being respected, and SAFETY is maintained.
The surveyors observe residents (e.g., to see if hand washing and
isolation protocols are followed and that ID badges are clearly
visible). And they may meet with residents to assess that residents
are familiar with the following:
* Who SUPERVISES whom (The Chain of Command).
* That residents have documentation of CREDENTIALING for any PROCEDURES
they say they are allowed to perform.
* That residents know how to get ASSISTANCE when they need it.
* That residents know how to get in touch with the ATTENDING (Captain
of the Ship) in a timely fashion, and that important diagnostic and
therapeutic issues are discuessed with the attending.
* That patient's symptoms of PAIN are assessed regularly and treated
(and that a form documenting this is in each chart). Also, that
other discomfort such as nausea or shortness of breath is addressed.
* That CONFIDENTIALITY is maintained (e.g. computer terminals are not
facing the hallway and screen is shut off when not in use, not
speaking about patients in public places (elevators, cafeteria).
* That there is a PATIENT BILL OF RIGHTS posted on each floor. This
includes the right to know who the physicians are, so always wear
your ID badge.
* That residents know policies regarding RESTRAINTS (for safety on the
med/surg service; for behavioral reasons on the psych service)
* That all H&Ps are completed in a timely fashion, legibly, and that
all sections are filled out (e.g., advance directives, health care
proxy, pap/pelvic, smoking cessation).
* That hospital has CONTINUOUS QUALITY IMPROVEMENT activities,
including:
-reporting and review of adverse events
-"core measures of quality" such as for CAP, AMI, CHF
-strategies to avoid "wrong procedure, wrong site, wrong patient"
* That residents know what to do in case of a FIRE (see the R.A.C.E
summary which should be attached to your ID badge) and number to
call (x4444).
R: Rescue People in immediate danger
A: Alarm Pull Fire Alarm Box or call x4444
C: Confine Close all doors & windows
E: Extinguish Use fire extiniguisher
* That residents know various hospital CODES: (Team 1, Red, Blue, Pink,
Signal D).
* That residents know how to respond to a DISASTER code or any of the
other codes.
* That residents know the "BELL CODE" in their area.
* That residents can quickly locate the FIRE ALARMS and FIRE
EXTINGUISHERS for their area & know how to use: (P.A.S.S.):
Pull the pin that locks the handle
Aim the extinguisher at the base of the fire
Squeeze the handle
Sweeep back & forth along the base of the fire
For more information:
D. Kramer-administration
P. Murphy-nursing
Josephine Jalandoni-QA/QI (Joji - 6471/6357/3914 **784)
Lulu Ibanez-QA/QI (x6408) 10/2005 JH
2007 NPSG Summary:
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ha
p_cah_npsgs.htm
2008 NPSG Proposed:
http://www.jointcommission.org/NR/rdonlyres/47F81056-2F85-494F-978A-
7CB0908D0DB4/0/08_potential_HAP_NPSG.pdf
Improve safety in use of anticoagulation (including education)
Early recognition and response when a patient's condition appears to be
sorsening (Rapid Response Team)
Prevention of harm to patient due to healthcare worker fatigue.
Prevent bue and catheter misconnections (e.g., use "line reconcilliation")
Suggestions:1. The hospital develops or adopts criteria for identifying
victims in each of the following situations: Physical assault Rape Sexual
molestation Domestic abuse Elder neglect or abuse Child neglect or abuse
*The Family Violence Prevention Fund is one resource that can be contacted
for further information: http://www.endabuse.org/
