Transcript JCI-Dark PP Presentation

1
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International Patient Safety Goals
(IPSG)
Improving Patient Safety
means . . .
Reducing Patient Harm
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Reducing Medical Errors
Challenges for Patient Safety
Leadership
 Move toward a more safety-oriented culture
 Practice proactive systems analysis & risk
reduction
 Standardize processes and equipment
 Ensure adequate and effective staffing
 Implement team training for all staff
 Encourage and support patient involvement
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 Promote effective communication
Systems Analysis in Health Care
 To identify vulnerabilities and hazardous
conditions that could (and, over time, will)
impact patient safety and quality of care.
 To focus the redesign of those systems and
processes to improve patient safety and
quality of care.
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A systematic evaluation of a health care
organization’s systems and processes:

Represents proactive strategies to reduce risk of
medical error and reflect good practices
proposed by leading patient safety experts

Incorporating these new tools into our
accreditation requirements is a significant step

Organizations taking responsibility for using the
IPSG to foster an atmosphere of continuous
improvement is even more important
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Implementation of IPSG….
PSG 1
PSG 2
PSG 3
PSG 4
PSG 5
PSG 6
Identify Patients Correctly
Improve Effective Communication
Improve the Safety of High-Alert
Medications
Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
Reduce the Risk of Health Care
Associated Infections
Reduce the Risk of Patient Harm
Resulting from Falls
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JCI 4th Edition
International Patient
Safety Goals

A collaborative process is used to develop policies and/or
procedures that address the accuracy of patient identification

Use at least two (2) ways to identify a patient:
•
•
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giving medications
giving blood and blood products
taking blood samples
taking other samples for clinical testing
providing treatment or procedure
The patient’s Room Number cannot be used as an identifier
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IPSG.1
Identify Patients Correctly
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The complete VO and TO or test result is written
down by the receiver of the order or test result.
Must use a verification “read back” of complete
order or test result
The order or test result is confirmed by the
individual who gave the order or test result
Policies and procedures support consistent
practice verifying the accuracy of verbal and
telephone communications
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IPSG 2: Improve Effective
Communication
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Policies/procedures are developed to address
identification, location, labeling and storage of
high-alert medications
Policies/procedures are implemented
Concentrated electrolytes are not present in
patient care units unless clinically necessary and
actions are taken to prevent inadvertent
administration
Concentrated electrolytes that are stored in
patient care units are clearly labeled and stored in
a manner that restricts access
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IPSG 3: Improve Safety of
High Alert Medications
– Has to be supported by evidence
– Is the substance really needed very
quickly?
– If it is used to dilute, is the diluted
solution available?
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Clinical Necessity

Collaboratively develop a policy/procedure that
includes:
 Definition of surgery that incorporates at
least those procedures that investigate
and/or treat diseases and disorders of the
human body through cutting removing,
altering, or insertion of
diagnostic/therapeutic scopes.
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IPSG 4: Ensure Correct-site,
Correct-procedure, Correctpatient Surgery
IPSG 4 Correct Site, Procedure
and Patient
– Use an instantly recognizable mark for
surgical site identification
– Involves the full surgical team and is
documented just before starting a surgical
procedure
– Policies/procedures are developed to support
uniform process to ensure correct site,
procedure, and patient (including medical and
dental procedures done in settings other than
the operating theater)
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– Involves the patient in the marking process
Checklist or other
process to verify:
DOCUMENTS
EQUIPMENT
PATIENT
Functional
& Correct
PROCEDURE
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SURGERY
SITE
– The organization has adopted or adapted
currently published and generally accepted
hand-hygiene guidelines
– Implements an effective hand-hygiene
program
– Policies/procedures are developed that
support continued reduction of health care
associated infections
Need data to demonstrate effectiveness
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PSG 5: Reduce the Risk of
Health Care-Associated
Infections
 Implements a process for the initial
assessment of patient for fall risk and
reassessment of patients when indicated by
a change in condition or medications,
among others
 Measures are implemented to reduce falls
risk for those at risk
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IPSG 6: Reduce the Risk
of Patient Harm resulting
from Falls
– Measures are monitored for results,
both successful fall injury reduction and
any unintentional related consequences
– Policies/procedures support continued
reduction of risk of patient harm
resulting from falls in the organization
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IPSG 6 Reducing Risk of Harm
Resulting from Falls
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Access to Care and
Continuity of Care (ACC)
1.
2.
3.
4.
5.
Admission to the Organization
Continuity of Care
Discharge, Referral, and Follow-up
Transfer of Patients
Transportation
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ACC-Five Areas of Focus
– Screening at point of first contact
– Determine if care can be provided
– Diagnostic test are available for
decision making-standardized by policy
– Patients are informed if any wait or
delay and reasons (waiting list)
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ACC.1 “ADMISSION” of In-Patients &
“REGISTRATION” of Out-Patients
– Policies & Procedures (PP) standardize
admission and registration for out-patients and
in-patients
– PP Admitting emergency patients
– PP Holding patients for observation
– PP Managing patients when bed space not
available
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ACC.1.1 Process of Admission or
Registration
– Evidence based triage process is used to
prioritize patients with immediate needs
– Staff are trained use of the triage process
– Staff prioritize patients based on urgency of
needs
– Emergency patients are assessed and
stabilized prior to transfer
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ACC.1.1.1 Emergency Patients
ACC.1.1.2 Needs are Prioritized
for In-patients
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Preventative
Palliative
Curative
Rehabilitative
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– Screening assessment identifies patient’s
needs
– Services or units are selected to meet needs
based on the assessment:
– In-patients and out-patients are
informed of delays
– Reason for delay and available
alternatives
– Documented in the patient medical
record
– Written policies/procedures
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ACC.1.1.3 Waiting Periods or
Delays
– Patient and Family receive information during
the admission process on:
– Proposed care
– Expected out comes of care
– Expected costs
– Sufficient information to make
knowledgeable decisions
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ACC.1.2 Information Provided
ACC.1.3 Reduction of Barriers
– Leaders and staff identify most common
barriers for patients
Physical
Language
Cultural
Other
– A process is identified and implemented
– to overcome or limit identified barriers
– to limit impact of barriers on delivery of services
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– Admission/transfer criteria established for Intensive and
Specialized Units
– Criteria are physiologic-based
– Appropriate individuals are involved in developing and
implementing the criteria
– Patients meet the criteria (documented)
– Patients are discharged/transferred when they no
longer meet criteria
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ACC.1.4 Criteria for Admission or
Transfer to Intensive Care
– Leaders design and support continuity
(coordination & resources)
– Criteria or policies determine transfers
within the organization
– Continuity and coordination is evident
throughout all phases of patient care and to
the patient
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ACC.2 Continuity of Patient Care
ACC.2.1 Individual Responsible
– The individual documents the patient plan of
care
– Transfer from one individual to another is
described in policy
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– There is an individual responsible for patient’s care
who is
– a physician or other person
– qualified to assume responsibility for care
– identified to the hospital staff
ACC.3 Referral and Discharge Policy
– Policy for the appropriate referral or discharge of patients
– Policy guides patients “on pass” for a defined period of
time
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– Based on patient’s needs for continuing care
– The patient’s readiness for discharge
– Discharge planning begins early and includes
the family as appropriate
– Discharge planning for both supportive and
continuing medical services
– Community providers, organizations and
individuals are identified
– Appropriate referrals are made (in the
patient’s home community whenever
possible)
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ACC.3.1 Cooperation with
Community Practitioners
ACC.3.2 Discharge Summary
– In-patient clinical records contain a discharge
summary prepared by a qualified individual
– Follow up instructions
– In the patient’s medical record
– Given to the patient at discharge
– Provided to practitioner responsible for continued
care
– Policy and procedure define discharge
summary
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– Copies are:
ACC.3.2.1 Discharge Summary
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Reason for admission
Significant physical and other findings
Significant diagnoses and co-morbidities
Diagnostic and therapeutic procedures
Significant medication and treatments
Condition at discharge
Discharge medications and all medications to be
taken at home
– Follow up instructions
Continued on next slide…..
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– Prepared at discharge, documented in the
patient’s record and contains:
ACC.3.2 Discharge Summary
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– Unless contrary to policy, laws, or culture,
patients are given a copy
– A copy is provided to the practitioner
responsible for patient’s continuing or followup care
– Identify which continuing care patients
require a summary
– Identify how the summary is maintained
and who maintains it
– Identify format and content of summary
– Define what is considered current
– Policy for completed summary
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ACC.3.3 Out Patient Summary of
Continuing Care
ACC.3.4 Understandable Follow
Up Instructions
– Follow up instructions are
understandable
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– Return for follow up care
– When to obtain urgent care
– Care necessary to patient’s condition
– Process for management and follow up
of in-patients and outpatients who leave
AMA
– Known family physicians are notified
– Applicable with local laws and
regualtions
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ACC.3.5 Against Medical Advice
ACC.4 Transfer Policy
– Patient’s need for continuing care
– Transfer of responsibility to another
provider or setting
– Who is responsible during transfer
– Situations where transfer is not possible
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– Guiding process for transferring patients
to include:
ACC.4.1 Referring and Receiving
Organizations
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– Referring organization determines whether
receiving organization can meet patient’s needs
– Arrangements (formal or informal) are in place
when patients are frequently transferred
ACC.4.2 Written Summary
– Patient status
– Procedures
– Other interventions provided
– Patient’s continuing care needs
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– Clinical summary is transferred with
patient & includes:
– All patients are monitored during direct
transfer
– Qualifications of the staff member doing
the monitoring are appropriate for
patient’s condition
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ACC.4.3 Monitoring Patients During
Transfer
ACC.4.4 Documentation of
Transfer
– Name of organization and individual
agreeing to receive patient
– Reason for transfer
– Any special conditions related to transfer
– Any change of patient’s condition or status
during transfer
– Any other notes require by the transferring
organization
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– Documentation includes:
– Assessment of transportation needs when referring
patients
– Transportation is arranged appropriate to patient
needs
– Owned transport vehicles meet laws and regulations
– Contracted transportation meets patient needs
– Appropriate equipment
– Monitoring the quality and safety or transportation
– Includes a complaint process
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ACC.5 Planning Transportation
Needs
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Patient and Family Rights (PFR)
1. Identify, Protect and Promote Patient
Rights
2. Inform Patients of Their Rights
Including Patient’s Family in Decisions
3. Informed Consent
4. Research
5. Organ Donation
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PFR – Six Areas of Focus
PFR.1 Processes Support Rights
– Leaders
– Staff members are knowledgeable and
can explain their responsibilities
– Policies and Procedures (PP) guide and
support patient and family rights
Continued on next slide
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– work collaboratively to protect and advance
patient and family rights
– understand rights as defined in laws and
regulations
PFR.1 Process Support Rights
– to have the prerogative to determine what
information is provided the family and others,
– and under what circumstances.
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– The hospital respects patient rights, and in
some cases the rights of patient’s family:
– There is a hospital process to identify and to
respect patient values and beliefs and those
of the family
– Staff members
– use the process
– provide care respectful of the patient’s
values and beliefs
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PFR.1.1 Patient’s Values and Beliefs
PFR.1.1.1 Spiritual Support
– There is a process to respond to
requests for religious or spiritual support
– Process is designed to accommodate:
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– Routine requests
– Complex requests
PFR.1.2 Patient Privacy
– Clinical interviews
– Examinations
– Procedures/treatments
– Transport
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– Staff members identify patient
expectations and needs for privacy
– The patient’s expressed need for
privacy is respected in all:
– The hospital defines to what extent it is
responsible for patient’s possessions
– Patients are informed of the hospital’s
responsibility
– Patient’s possessions are safeguarded when
the hospital assumes responsibility or when
the patient is unable to assume responsibility
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PFR.1.3 Patient Possessions
– There is a process to protect patients from
assault
– Those addressed in the process are:
– Infants, Vulnerable children, Elderly
– Others unable to protect themselves
– Individuals without identification are
investigated
– Remote or isolated areas are monitored
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PFR.1.4 Physical Assault
PFR.1.5 Appropriate Protection
– Children, disabled individuals, elderly
– Others identified by the hospital
– Staff members understand their
responsibilities for protection
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– Leaders identify vulnerable patient
groups
– Those protected include:
PFR.1.6 Confidential Information
– How their information will be kept
confidential and about laws and regulations
that require the release and/or require
confidentiality of patient information
– Patients are requested to grant permission
to release information not covered by law
and regulation
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– Patients are informed about:
– Policies support and promote patient and
family participation in care processes
– Policies and procedures address the right
to seek a second opinion without fear of
compromised care
– Staff members are trained on their role in
supporting participation in care processes
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PFR.2 Participation in Care
PFR.2.1 Patient Information
– medical conditions and any confirmed
diagnosis
– planned care and treatment
– when consents will be requested and the
process used
– their right to participate in care decisions
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– Patients & families understand how and
when they will be told about
PFR.2.1.1 Outcomes of Care
– how they will be told and who will tell them
of the outcomes of care and treatment
– how they will be told and who will tell them
of any unanticipated outcomes of care and
treatment (out come of treatment including
unanticipated outcome)
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– Patients and families understand
PFR.2.2 Right to Refuse or
Discontinue Care
– their rights to refuse or discontinue care
– the consequences of their decisions
– their responsibilities related to such
decisions
– available care and treatment alternatives
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– Patient and families will understand:
PFR.2.3 Withholding Resuscitation/
Withdrawing Life Support
– Hospital defines its position
– Hospital’s position conforms to:
– Community’s religious and cultural norms
– Any legal or regulatory requirements
– How to make their decisions known
– How to modify decisions during care
– Policies & procedures guide:
– Hospital’s response to patient’s decisions
– Documentation about decisions
– The ethical and legal issues related to carrying out
the patient’s wishes
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– Policies guide patients on:
– The organization respects and supports the
patient’s right to appropriate assessment and
management of pain
– Staff understand the personal, cultural, and
social influences on the patients right to:
– report pain
– accurately assess and manage pain
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PFR.2.4 Assessment of Pain
PFR.2.5 End of Life Care
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– Hospital staff recognizes that dying
patients have unique needs
– Staff respects the right of dying patients to
have those unique needs addressed in
the care process
PFR.3 Complaints and Conflicts
– complaints
– dilemmas that arise during care
– PP identify
– participants in the process
– how the patient and family participate
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– Patients are aware of their right to voice
a complaint and the process to do so
– The hospital has and uses a mechanism
to review:
PFR.4 Education of Staff
– their role in identifying patient and family
values and beliefs
– how these values and beliefs can be
respected in the care process
– their role in protecting patient and family
rights
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– Staff members understand:
– Patients receive information about their rights
in writing
– The hospital has a process to inform patients
or families of their rights when written
communication is not effective or appropriate
– Language
– Illiteracy
– Medical condition
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PFR.5 Patients are Informed of Rights
PFR.6 Patients Receive Information
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– Policy and procedure contain a clearly
defined informed consent process
– Patients give consent consistently with policy
– Designated staff are trained consistently with
policy
PFR.6.1 Adequate Information
– their condition
– proposed procedures and treatments and who is
authorized to perform them
– potential benefits and drawbacks and possible
problems related to recovery
– alternatives to the proposed treatment and results
of possible non–treatment
– likelihood of success of treatments
– Patients know the identify of the physician or
practitioner responsible for their care
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– Patients are informed about:
– The hospital has a process for when
others can grant informed consent
– The process is consistent with law,
culture, and custom
– The individual giving consent is
documented in the patient’s record
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PFR.6.2 Others Giving Consent
PFR.6.3 General Consent
– the scope of a General Consent is clear
– the General Consent is documented per
hospital policy
– However, the standards do not require a
General Consent
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– If General Consent is obtained at the
time of admission or registration for the
first time as an out-patient, then:
PFR.6.4 Required Informed
Consents
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Surgical or invasive procedures
Anesthesia other than local
Moderate (“conscious”) and deep sedation
Blood and blood products
High-risk procedures and treatments
– Required documentation in the medical record:
– Identity of the individual providing information to
patient and family
– Patient’s signature or a record of verbal consent
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– Consent is obtained before:
– The hospital has a list of those
operations, procedures, and treatments
that require a separate consent
– The list is developed collaboratively by
physicians and others that provide the
treatments and perform the procedures
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PFR.6.4.1 Specific Consents
PFR.7 Access to Research
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Expected benefits
Potential discomforts and risks
Alternatives that might help them
Procedures that must be followed
Refusal to participate or withdraw will not
compromise their access to services
– Relevant only if research is done in the
hospital
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– Patients who may benefit from participating in
research are identified and informed about
how to gain access to research
– Patients asked to participate are informed
about:
PFR.7.1 Research Patients are
Protected
– Reviewing research protocols
– Weighing the benefits and risks
– Obtaining consent
– Withdrawing from participation
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– Patients and families are informed
about the hospital’s process for:
– Informed consent is obtained when the
patient decides to participate
– Consent decisions are documented, dated
– The individual providing the information is
documented in the patient’s record
– Consent is documented in the medical
record by signature of the patient or record
of verbal consent
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PFR.8 Informed Consent for
Research
PFR.9 Oversight of Research
– A clear statement of the purpose of oversight
activities
– A review process
– A process to weigh relative risks and benefits
– Processes to provide confidentiality and security of
research information
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– The organization has a committee or other
mechanism to oversee research:
– Oversight includes:
PFR.10 Organ Donation
– The hospital
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– supports patient and family choices to
donate organs and other tissue
– provides information to support the choice
PFR.11 Oversight
– Policy and procedure guide:
– the procurement and donation process
– the transplantation process
– in the policy
– in the issues and concerns related to organ
donation and the availability of transplants
– The hospital cooperates with the relevant
organizations and agencies in the community
to respect and implement choices to donate
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– Staff is trained:
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Assessment of Patients (AOP)
1. Collecting and Analyzing Patient Data
and Information
2. Laboratory Services
3. Radiology and Diagnostic Imaging
Services
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AOP – Three Areas of Focus
AOP.1 – AOP.1.1
Assessment Process
– AOP.1 Hospital PP:
– AOP.1.1 The scope and content of
assessments are defined in policies:
– For each clinical discipline
– For inpatient and outpatient settings
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– define the assessment information to be obtained
for
– inpatients
– outpatients
– identify the information to be documented for the
assessments
AOP.1.2 Initial Assessment
– Inpatients and outpatients have an initial
assessment that meets hospital policy
(Note that by AOP.1 and 1.1, inpatient and
outpatient assessments may be very different)
– A medical assessment including a health history
and physical examination
– A psychological assessment appropriate to needs
– Social and economic as appropriate to needs
Continued on next slide
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– Initial assessment includes, according to
hospital policy:
AOP.1.2 Initial Assessment
– The initial assessment results in:
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– Understanding any previous care and the care the
patient is currently seeking
– Selecting the best setting for the care
– An initial diagnosis
AOP.1.3 Patient’s Needs
Identified
– The initial assessment results in:
– Medical needs are identified based on the
documented H&P and other required hospital
assessments
– Nursing needs are identified based on the
nursing assessment, the medical assessment
and other required hospital assessments
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– Identification of patient’s medical needs
– Identification of patient’s nursing needs
AOP.1.3.1 Assessment of
Emergency Patients
– Emergency patients have:
– If emergency surgery is performed, the
following are recorded before the operation:
– A brief assessment note
– A preoperative diagnosis
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– Medical assessment appropriate to their needs
and condition
– Nursing assessment appropriate to their needs
and condition
– Assessment time frames are established
for all settings and services
– The initial medical and nursing
assessments are conducted within the
first 24 hours or earlier as indicated by the
patient’s condition or hospital policy
(AOP.1.4.1)
– Assessments are completed in the
established time frames
– Assessments from outside the
organization are reviewed/verified at the
time of admission to inpatient status
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AOP.1.4 – AOP.1.4.1 Time
Frames
AOP.1.4.1 Assessments
Performed Before Admission
– For any assessment conducted more than 30
days prior to:
the medical history has been updated and the
physical examination repeated
– For any assessment less than 30 days old,
any significant changes in the patient’s
condition are noted at the time of admission
to inpatient status
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– admission to inpatient status or
– an outpatient procedure
AOP.1.5 Assessments are Available
– For other than medical and nursing assessments,
there can be a summary note in the patient’s
record, with a fuller description in the concerned
department as long as there is access to them
(see Intent Statement)
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– Assessments are documented in the patient’s
medical record
– Individuals caring for the patient can find and
retrieve assessments as needed
– Medical and nursing assessments are
documented within 24 hours of admission
– Medical assessment is performed prior
to surgery
– Medical assessment is documented
prior to surgery
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AOP.1.5.1 Assessments before
Anesthesia or Surgery
– Qualified individuals develop criteria to
identify patients who require further nutritional
and/or functional assessment
– Patients are screened for nutritional risk
and/or functional risk as part of the initial
assessment
– Patients identified for additional assessment
based on the criteria that identifies additional
needs, receive additional assessments for
nutritional and/or functional needs
– (Functional risk means having one or more skill
needed for the activities of daily living impaired)
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AOP.1.6 Nutritional and Functional
Screening
AOP.1.7 Special Populations
– Very young patients
– Frail elderly
– Terminally ill and others in pain
– Women in labor
– Those with emotional or psychiatric disorders
– Those suspected of drug and/or alcohol dependency
– Victims of abuse and neglect
– The initial assessment is for these populations is
modified (i.e. patients belonging to these special
populations receive individualized assessments)
91
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– The hospital identifies special populations,
including at least:
– When the need for additional
specialized assessments are identified,
patients are referred within or outside
the organization, as appropriate
– Additional specialized assessments
completed within the organization are
documented
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AOP.1.8 Specialized
Assessments
AOP.1.9 Dying Patients and
Their Families
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– Dying patients and their families are
assessed and reassessed
– Findings guide care and services
– Findings are documented
AOP.1.10 Specialized Assessments
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– Patients are referred within the
organization when the need for
specialized assessments are identified
– Completed and documented
AOP. 2 Reassessment
– Patients are reassessed:
Continued on next slide
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– To determine their response to treatment
– To plan for continued treatment or discharge
– At intervals appropriate to their condition, plan
of care and individual needs and hospital PP
AOP. 2 Reassessment
– A physician reassesses patients daily during
acute phase of care
– Daily means including weekends and holidays
– Circumstances, types of patients, or patient
populations (i.e. define non-acute population)
– Policy identifies the reassessment interval for
these patients
– All reassessments are documented
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– Policy defines when physician reassessment
less often than daily is acceptable based on:
AOP.3 Qualified Individuals
– Only those permitted by licensure, applicable laws and
regulations or certifications can perform the
assessments
– Emergency assessments are conducted by identified
and qualified individuals
– Nursing assessments are conducted by identified and
qualified individuals
– Those qualified to conduct assessments and
reassessments have their responsibilities defined
in writing (by clinical privilege or job description)
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– Individuals qualified to assess and reassess are
identified by the hospital
– Patient assessment data and
information are analyzed and
integrated
– Those responsible for the patient’s
care participate in the process
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AOP.4 Collaboration to Integrate
Assessments
AOP.4.1 Patient Needs Prioritized
– The outcomes of the assessments and
any confirmed diagnosis as appropriate
– The planned care and treatment and
participate in the decisions about the
priority needs
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– Patient needs are prioritized based on
assessment results
– Patients and families are informed of:
AOP.5 Laboratory Services
– Laboratory services
– Emergency laboratory services are available
– Outside services are selected based on
acceptable compliance with laws and
regulations
– Patients are informed about any relationships
between the referring physician and outside
laboratory services
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– meet applicable local and national standards, laws
and regulations
– are adequate, regular, and convenient
– Laboratory safety program is
– in place and is appropriate to the risks and hazards
– coordinated with the hospital safety management
program
– PP address the handling and disposal of infectious and
hazardous material
– Safety devices are available and appropriate
– Staff are oriented to the safety program
– Staff receive education
– for new procedures
– for newly acquired or recognized hazardous
materials
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AOP.5.1 Lab Safety Program
AOP.5.2 Staff Training for
Testing
– Administer tests
– Interpret tests
– Are adequate in numbers to meet needs
– Supervisory staff have appropriate training
and experience
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– Staff who perform testing and those who
supervise are identified
– Appropriately trained and experienced
staff:
AOP.5.3 Laboratory Results Timing
– Expected report time for results has been
established
– Timeliness of reporting urgent/emergency
tests is monitored
– Tests are reported within a time frame to
meet patient needs
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– (Established collaboratively – see GLD.5.1.1,
MCI.5)
AOP.5.3.1 Critical Results
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– Collabortive method used to develop
processes for reporting critical results
– Define critical test values
AOP.5.4 Equipment Maintenance
–
–
–
–
–
–
Selecting and acquiring equipment
Inventorying equipment
Inspecting and testing equipment
Calibrating and maintaining equipment
Monitoring and follow-up
Adequately documenting the above requirements
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– Laboratory equipment management is
implemented
– The program includes:
AOP.5.5 Available Reagents
– Identified
– Available
– Stored and dispensed according to
guidelines
– Evaluated for accuracy and results
– Completely and accurately labeled
according to guidelines
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– All reagents, supplies and solutions are:
– Procedures for specimens guide:
– Ordering tests
– Collection and identification of specimens
– Specimen transport, storage and
preservation
– Specimen receipt and tracking
– Procedures are
– implemented
– observed when outside sources or service
are used
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AOP.5.6 Specimen Handling
– Reference ranges are established for each
test
– Ranges are:
– Included in the clinical record when results
are reported
– Provided when tests are performed by
outside sources
– Appropriate to the hospital’s geography
and demographics
– Reviewed and updated as needed
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AOP.5.7 Test Ranges
– Qualified individual(s) provide direction and oversight
for all clinical laboratories
– Responsibilities include:
– Developing, implementing and maintaining policies
and procedures
– Administrative oversight
– Quality Control (QC) programs
– Recommending outside sources
– Monitoring and reviewing all services within and
outside the laboratory
– This includes point of care testing (see Intent
Statement)
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AOP.5.8 Qualified Director
– The QC Program includes:
– Validation of test methods
– Daily surveillance of test results
– Rapid correction of deficiencies
– Testing of reagents
– Documentation of results and corrective
actions
– The program is implemented
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AOP.5.9 Quality Control
– Participation in a proficiency testing
program or an alternative for all
specialty laboratory services and tests
– External QC is an acceptable
alternative
– A cumulative record of participation is
maintained
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AOP.5.9.1 Proficiency Testing
AOP.5.10 Outside Services
– QC results from outside sources are
regularly reviewed
– Qualified individuals review the QC results
– A roster of experts for specialized diagnostic
areas is maintained
– Experts in specialized areas are contacted
when needed
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AOP.5.11 Experts
– Radiology and diagnostic imaging
services meet applicable local and
national standards, laws and regulations
– Adequate, regular and convenient
services are available to meet needs
– Emergency services are available after
normal hours of operation
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AOP.6 Imaging Services
– Outside services are selected based on
recommendations of the director and an
acceptable record of timely performance
and compliance
– Patients are informed about any
relationships between referring
physicians and recommended outside
sources of radiology and diagnostic
imaging services
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AOP.6.1 Referral for Diagnostic
Imaging
– Radiation Safety Program is in place and
coordinated with the hospital’s safety and
management program
– The program includes radiology and diagnostic
imaging services as well as radiation oncology
and the cardiac catheterization laboratory (See
Intent Statement)
– Note that Nuclear Medicine is not mentioned; however,
it is included by law or regulation in most countries
Continued on next slide
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AOP.6.2 Radiation Safety
Program
AOP.6.2 Radiation Safety
Program
– PP address:
– Radiation safety devices are available
– Staff are oriented to
– safety procedures and practices
– new procedures and equipment hazards
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– Compliance with applicable standards and laws
and regulations
– Handling and disposal of infectious and hazardous
materials (See also PCI.7.1, FMS.5)
– Staff who perform diagnostic and imaging studies and
those who supervise are identified
– Appropriately trained and experienced staff:
– perform studies
– interpret study results
– (who interprets X-rays from the ER after hours?)
– verify and report results
– are of adequate numbers
– Supervisory staff have appropriate training and
experience
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AOP.6.3 Imaging Staff Training
– Expected report time for results has been
established
– Timeliness of reporting urgent/emergency
tests is monitored
– Tests are reported within a time frame to
meet patient needs
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AOP.6.4 Timely Results of Reports
AOP.6.5 Equipment Maintenance
–
–
–
–
–
–
Selecting and acquiring equipment
Inventorying equipment
Inspecting and testing equipment
Calibrating and maintaining equipment
Monitoring and follow-up
Adequately documenting the above requirements
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– Radiology and Diagnostic Imaging
equipment management is implemented
– The program includes:
AOP.6.6 Available Supplies
– Identified
– Available
– Stored and dispensed according to
guidelines
– Evaluated for accuracy and results
– Completely and accurately labeled
according
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– All x-ray film, reagents and supplies are:
AOP.6.7 Qualified Director
– Developing, implementing and maintaining policies
and procedures
– Administrative oversight
– QC programs
– Recommending outside sources
– Monitoring and reviewing all services
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– Qualified individual(s) provide direction and
oversight for all radiology and diagnostic
imaging services
– Responsibilities include:
AOP.6.8 Quality Control
– Validation of test methods
– Daily surveillance of imaging results
– Rapid correction when a deficiency is
identified
– Testing of reagents and solutions
– Documentation of results and corrective
actions
– The program is implemented
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– The QC Program includes:
AOP.6.9 Outside Services
– QC results from outside sources are
regularly reviewed
– Qualified individuals review the QC results
– A roster of experts for specialized diagnostic
areas is maintained
– Experts in specialized areas are contacted
when needed
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AOP.6.10 Experts
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Care of Patients (COP)
1. Uniform Care Delivery
2. Care of High – Risk Patients and
Provision of High – Risk Services
3. Food and Nutrition Therapy
4. Pain Management and End-of Life
Care
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COP-Four Areas of Focus
COP.1 Uniform Care Processes
– Clinical and Managerial leaders provide uniform
care processes
– PP guide uniform care; reflect laws & regulations
–
–
–
–
–
Not dependent on ability to pay
Needed care given independent of day of week or time
Acuity of patient determines resources applies
Same services delivered the same way everywhere
Patients with same nursing services receive same care
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– Uniform care is provided that meets the five
requirements of the intent
COP.2 Integration & Coordination
of Care
– Care Planning and Care Delivery are
integrated and coordinated among:
– Results from any patient care team meetings
or other collaborative discussions are written
in the patient’s record
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– Settings
– Departments
– Services
COP.2.1 Care is Planned
– The care for each patient is planned by:
– Plan made within 24 hrs of admission of inpatient
– Planned care is individualized and based on the
patient’s initial assessment data
– The plan is updated or revised as needed
– The care provided for each patient is written in the
patient’s record by the person providing the care
– The care planned is provided
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– Responsible physician
– Nurse
– Other healthcare professionals
– Orders are written when required and are
followed by organization policy
– Diagnostic imaging and clinical laboratory test
orders include a clinical indication/rationale
when required for interpretation
– Only those permitted to write orders do so
– Orders are found in a uniform location in the
patient records
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COP.2.2 Patient Orders
– Procedures performed are written into
the patient’s record including;
endoscopies, cardiac catheterization
and other invasive and noninvasive
diagnostic and treatment procedures
– The results of procedures performed
are written into the patient’s record
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COP.2.3 Procedures
COP.2.4 Outcomes of Care
– Patients and families are informed
about:
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– Outcomes of their care and treatment
– Any unanticipated outcomes of their care
and treatment
COP.3 (and COP.3.1 – 3.9) Policy &
Procedure -High-Risk Patients and Services
Continued on next slide
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– Leaders identify high-risk patients and services
– Develop policies and procedures
– Staff are trained and use PP to guide care
– The following must be reflected in PP for COP.3.1 3.9:
– how planning will occur including the identification of
differences between adult and pediatric populations,
or other special considerations
– the documentation required for the care team to
work and communicate effectively
– special consent considerations (if appropriate)
– patient monitoring requirements
– special qualifications or skills of staff involved
– availability and use of specialized equipment
Continued
on next slide
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COP.3 (and COP.3.1 – 3.9) Policy &
Procedure -High-Risk Patients and Services
– COP.3.1 Care of emergency patients
– COP.3.2 Resuscitation
– COP.3.3 Handling, use, administration of blood and
blood products
– COP.3.4 Care of comatose patients
– COP.3.4 Care of patients who are on life support
– COP.3.5 Care of patients with communicable disease
– COP.3.5 Care of immune-suppressed patients
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COP.3.1-3.9 Patients – Processes
–
–
–
–
–
–
–
COP.3.6 Care of patients on dialysis
COP.3.7 Use of restraint
COP.3.8 Care of frail, dependent elderly patients
COP.3.8 Care of young, dependent children
COP.3.8 Care of patients at risk for abuse
COP.3.9 Care of patients receiving chemotherapy
COP.3.9 Care of patients receiving other high-risk
medications
– Leaders to establish which medications are high-risk
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COP.3.1-3.9 Patients – Processes
COP.4 Food Choices
– Food or nutrition, appropriate to the patient, is
regularly available.
– All patients have an order for food in their
record.
– Patients have a variety of food choices
consistent with their condition and care.
– When families provide food, they are
educated about the patient’s diet limitations.
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– The order is based on the patient’s nutritional
status and needs.
– Food is prepared and stored in a manner that
reduces risk of contamination and spoilage.
– Enteral nutrition products are stored
according to manufacture recommendations
and organization policy.
– The distribution of food is timely, and special
requests are met.
– Practices meet applicable laws, regulations,
and acceptable practices.
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COP.4.1 Food Preparation
– Patients assessed at nutrition risk
receive nutrition therapy.
– A collaborative process is used to plan,
deliver, and monitor nutrition therapy.
– The patient’s response to nutrition
therapy is monitored.
– The patient’s response to nutrition
therapy is recorded in his/her record.
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COP.5 Nutritional Risk Patients
COP.6 Pain Management
– The hospital has processes to:
– Patients in pain receive care according to
pain management guidelines
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– Identify patients in pain
– Communicate with and educate patients and
families about pain
– Educate staff about pain
– Staff are made aware of patients’ unique needs at the
end of life.
– End-of-life care includes:
– providing appropriate treatment for any symptoms
according to the wishes of the patient and family
– sensitively addressing issues such as autopsy and
organ donation
– respecting the patient’s values, religion, and cultural
preferences
– involving the patient and family in all aspects of care
– responding to the psychological, emotional,
spiritual, and cultural concerns of the patient/family
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COP.7 End-of-Life Care
COP.7.1 Individual Needs
– Psychosocial, emotional and spiritual needs
– Religious and cultural concerns
– Patient and family are involved in the
process
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– Interventions are taken to manage pain
and other symptoms
– Symptoms and complications are
prevented to the extent possible
– Interventions address:
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Anesthesia and Surgical Care (ASC)
ASC-Four Areas of Focus
Organization and Management
Sedation Care
Anesthesia Care
Surgical Care
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1.
2.
3.
4.
Applicability Statement
–
–
–
–
–
–
hospital operating theatres,
day surgery or day hospital units,
dental and other outpatient clinics,
emergency services,
intensive care areas,
or elsewhere.
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– The ASC standards are applicable to what
ever setting anesthesia and/or moderate or
deep sedation are used and surgical and
other invasive procedures that require
consent are performed, including
ASC.1 Anesthesia Services
– Anesthesia services
– meet local and national standards and laws and regs
– are available to meet patient needs and are:
– adequate, regular and convenient
– Outside anesthesia sources are selected based on
recommendations of the director and
– an acceptable record of performance
– compliance with applicable laws and regs
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– available for emergencies after normal hours of
operation
– Anesthesia services are uniform and under the
direction of one or more qualified individuals
– Responsibilities include
– developing, implementing, and maintaining PP
– administrative oversight
– maintaining quality control programs
– recommending outside sources of anesthesia
services
– include monitoring and reviewing all anesthesia
services
– The individuals carries out the responsibilities
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ASC.2 Qualified Director
Moderate Sedation:
Deep Sedation:
•Patients respond
purposefully to verbal
commands
•No interventions are needed
to maintain a patent airway
•Cardiovascular function is
usually maintained
•Patients cannot be easily
aroused but respond
purposefully after repeated
or painful stimulation
•Airway may be impaired
•Cardiovascular function is
usually maintained
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Sedation
– Policy and procedure for moderate and deep
sedation address:
– How planning will occur including the identification
of differences between adult and pediatric
populations, or other special considerations
– Documentation required for the care team to work
and communicate effectively
– Special consent considerations, if appropriate;
– Patient monitoring requirements;
– Special qualifications or skills of staff involved in
sedation process
– Availability and use of specialized equipment
Continued on next slide
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ASC.3 Sedation
ASC.3 Sedation
–
–
–
–
–
Techniques of various modes of sedation,
Appropriate monitoring,
Response to complications,
Use of reversal agents, and
At least basic life support.
Continued on next slide
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– The qualified individual(s) identified in ASC.2
participates in the development of the Policies &
Procedures
– There is a pre-sedation assessment to evaluate risk
and appropriateness of the sedation for the patient
– The practitioner responsible for sedation is qualified
in at least:
– A qualified individual (other than the one
performing the procedure) monitors the
patient during sedation and during the
period of recovery from sedation and
documents the monitoring
– Moderate and deep sedation are
administered according to hospital
policy.
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ASC.3 Sedation
– A pre-anesthesia assessment is performed
for each patient.
– Patients are re-evaluated immediately before
the induction of anesthesia.
– The two assessments are performed by
individual(s) qualified to do so.
– The two assessments are documented in the
clinical record
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ASC.4 Pre-Anesthesia Assessment
ASC.5 Anesthesia Plan
– The anesthesia care of each patient is planned
– The plan is documented
•The patient, family, and decision-makers are
educated on the risks, benefits and alternatives
of anesthesia
•The anesthesiologist or another qualified
individual provides the education
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ASC.5.1 Patient Counseling
ASC.5.2 Anesthesia Technique
– The anesthesia used and the anesthetic
technique are written into the patient’s
anesthesia record
– Physiological status is continuously
monitored during anesthesia administration
– The results of monitoring are written
into the patient’s anesthesia record
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ASC.5.3 Monitoring
– Patients are monitored appropriate to
their condition during the postanesthesia recovery period
– Monitoring findings are entered into
the patient’s record
– Recovery area arrival and discharge
times are recorded.
Continued on next slide
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ASC.6 Post-Anesthesia
ASC.6 Post-Anesthesia
– By a fully qualified anesthesiologist or other individual
authorized by the individual responsible for managing
the anesthesia services.
– By a nurse or similarly qualified individual in
accordance with post-anesthesia criteria developed by
the hospitals’ leaders, and is documented in the
patient’s record.
– The patient is discharged to a unit which has been
designated as appropriate for post-anesthesia or postsedation care of selected patients, such as a
Cardiovascular ICU, Neurosurgical ICU, etc.
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– Patients are discharged from the postanesthesia unit by one of 3 alternatives:
ASC.7 Surgical Care
– Each patient’s surgical care is planned
and documented
– A preoperative diagnosis is documented
prior to the procedure
– The planned surgical care is
documented prior to the procedure
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– The planning process considers all
available assessment information
– The patient, family, and decision-makers are
educated on the risks, benefits, potential
complications and alternatives related to the
planned surgical procedure.
– The education includes the need for, risk and
benefits of, and alternatives to blood and
blood product use.
– The patient’s surgeon or other qualified
individual provides the education.
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ASC.7.1 Risks, Benefits, and
Alternatives
– Written report includes:
– A postoperative diagnosis
– Names of the surgeon and surgical assistants
– Name of procedure
– Surgical specimens sent for examination
– Complications or absence of complications
– Amount of blood loss
– Date, time and signature of responsible physician
– The written surgical report, or a brief note in the
patient’s record, is available before the patient leaves
the post-anesthesia recovery area.
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ASC.7.2 Surgery Report
ASC.7.3 Patient Monitoring
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– The patient’s physiological status is
monitored continuously during surgery
– Findings are entered into the patient’s
record
– Each patient’s medical, nursing, and other
post-surgical care is planned.
– The plan(s) is documented in the patient’s
record
– Nursing postsurgical plan is documented
– When indicated-postsurgical POC provided
by others is documented
– POC is documented in pt. recorded within 24
hours
– Care is provided
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ASC.7.4 Post-Surgical Care
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Medication Management and
Use (MMU)
The Medication Management
Processes
Procurement
Monitoring
Storage
Administration
Ordering and
Transcribing
Preparing and
Dispensing
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Selection and
The Medication Use Process
Order
Verify
Prepare
Administer
Monitor
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Dispense
1.
2.
3.
4.
5.
6.
7.
Organization and Management
Selection and Procurement
Storage
Ordering and Transcribing
Preparing and Dispensing
Administration
Monitoring
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MMU-Seven Areas of Focus
– There is a plan or policy or other document that
identifies how medication use is organized and
managed throughout the organization
– All settings, services and individuals who
manage medication processes are included in
the organizational structure
– Policies guide all phases of medication
management and medication use in the
organization
Continue
on next slide
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MMU.1 Organization & Management
– There has been at least one documented
review of the medication management system
within the previous 12 months
– The pharmacy or pharmaceutical service and
medication use comply with applicable laws
and regulations.
– Appropriate sources of drug information are
readily available to those involved in
medication use.
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MMU.1 Organization &
Management
– An appropriately licensed, certified, and
trained individual supervises all
activities.
– The individual provides supervision for
the processes described in MMU.2 MMU.5 Standards
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MMU.1.1 Pharmacy Supervision
MMU.2 Selection of Medications
– (unless determined by regulation or an authority
outside the organization)
– There is a process established for when
medications are not available that includes a
notification to prescribers and suggested
–
substitutions
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– There is a list (formulary) of medications
stocked in the hospital or readily available from
outside sources.
– A collaborative process was used to develop
the list
– There is a method for overseeing medication
use in the organization
– Medications are protected from loss or theft
throughout the organization.
– Health care practitioners involved in ordering,
dispensing, administering, and monitoring
processes are involved in monitoring and
maintaining the medication list.
Continue on next slide
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MMU.2.1 Oversight of List
– Decisions to add or remove medication
from the list are guided by criteria.
– There is a process or mechanism to
monitor patient response to medications
newly added to the list.
– The list is reviewed at least annually
based on safety and efficacy
information.
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MMU.2.1 Oversight of List
MMU.2.2 Medication Availability
– There is a process to
– Staff understands the processes
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– approve and procure required medications
not stocked or normally available to the
organization.
– obtain medications at times the pharmacy
is closed or medication supply locked.
MMU.3 Storage of Medications
–Medications are stored under conditions
suitable for product stability
–Controlled substances are accurately
accounted for according to applicable
law and regulation
–Medications and chemicals used to
prepare medications are accurately
labeled with contents, expiration dates,
and warnings
Continue on next slide
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– In all locations that medications are
stored, the following is evident:
– All medication storage areas are periodically
inspected according to hospital policy to
ensure medications are stored properly
– Organization policy defines how medications
brought in by the patient are identified and
stored
– Storage of concentrated electrolytes is scored
at IPSG 3
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MMU.3 Storage of Medications
MMU.3.1 Special Storage
– Hospital policy defines how:
– All storage is according to organization
policy
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– Nutrition products are stored
– Radioactive, investigational and similar
medications are stored
– Sample medications are stored and
controlled
MMU.3.2 Emergency
Medications
– available in the units they will be needed or
readily accessible to meet emergency
needs
– Policy defines how emergency meds are
stored, maintained, and protected from loss
or theft
– monitored and replaced in a timely manner
after use or when expired or damaged.
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– Emergency medications are
MMU.3.3 Medication Recall
– any use of medications known to be
expired or outdated
– the destruction of medications known to be
expired or outdated
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– There is a medication recall system in
place.
– PP address
MMU.4 Prescribing, Ordering and
Transcribing
– Policies and procedures guide:
– Safe prescribing
– Ordering
– Transcribing
related to illegible prescriptions and orders
– Relevant staff is trained in correct prescribing,
ordering, and transcribing practices
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– Policies and procedures address actions
– Patient records contain a list of current
medications taken prior to admission
and this information is made available to
the pharmacy and the patient’s care
providers
– Initial medication orders are compared
to medications taken prior to admission
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MMU.4 Prescribing, Ordering and
Transcribing
–
Acceptable medication orders or prescriptions are
defined in policies:
– The data necessary to accurately identify the patient
– The elements of the order or prescription
– When generic or brand names are acceptable or
required
– Whether or when indications for use are required on
a PRN (as needed) or other medication order
– Special precautions or procedures for ordering drugs
with look-alike or sound-alike names
Continue
onPresentation
next slide
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MMU.4.1 Medication Orders
– Acceptable medication orders or prescriptions are
defined in policies:
– Actions to be taken when medication orders are
incomplete, illegible, or unclear.
– The permitted additional types of orders such as
emergency, standing, automatic stop orders and
any elements required in such orders
– The use of verbal and telephone medication orders
and the process to verify such orders
– The types of orders that are weight-based such as
for pediatric populations
Continued on next slide
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MMU.4.1 Medication Orders
MMU.4.1 Medication Orders
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– Medication orders or prescriptions are
complete per organization policy.
– Only those permitted by the organization and
by relevant licensure, laws and regulations
prescribe or order medications
– There is a process to place limits, when
appropriate, on the prescribing or ordering
practices of individuals.
– Individuals permitted to prescribe and order
medications are known to the pharmaceutical
service or others who dispense medications.
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MMU.4.2 Qualified Individuals
MMU.4.3 Medication Documentation
– Medications prescribed or ordered are
recorded for each patient
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– Administration is recorded for each dose.
– Information is kept in the patient’s record or
inserted into his or her record at discharge or
transfer
– Medications are prepared and
dispensed in clean and safe areas with
appropriate equipment and supplies
– Medications preparation and dispensing
adhere to law, regulation, and
professional standards of practice
– Staff preparing sterile products are
trained in aseptic techniques
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MMU.5 Preparing and
Dispensing
– The hospital defines the patient-specific information
required for an effective review process
– There is a process to contact the individual who
prescribed or ordered the medication when questions
arise
– Individuals permitted to review orders or
prescriptions are judged competent to do so
– Review is facilitated by a record (profile) for all
patients receiving medications
– Computer software, when used to cross check drugs,
is periodically updated
Continued on next slide
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MMU.5.1 Orders are Reviewed
MMU.5.1 Orders are Reviewed
– the appropriateness of the drug, dose, frequency,
and route of administration,
– therapeutic duplication
– real or potential allergies or sensitivities
– real or potential interactions between the
medication and other medications or food
– variation from hospital criteria for use
– patient’s weight & other physiological information
– other contraindications
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– Each prescription or order is reviewed for
appropriateness prior to dispensing
– There is a uniform medication dispensing and
distribution system in the organization.
– Medications are appropriately labeled after
preparation
– Medications are dispensed in the most ready
to administer form
– The system supports accurate and timely
dispensing
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MMU.5.2 Dispensing
– The hospital identifies those individuals, by
job description or the privileging process,
authorized to administer medications
– Only those permitted by the hospital and by
relevant licensure, laws and regulations
administer medications
– There is a process to place limits, when
appropriate, on the medication administration
of individuals
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MMU.6 Individuals Qualified to
Administer Medications
– Medications are verified with the prescription
or order
– The dosage amount of the medication is
verified with the prescription or order
– The route of administration is verified with the
prescription or order
– Medications are administered on a timely
basis
– Medications are administered as prescribed
and noted in the patient’s record
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MMU.6.1 Verification Before
Administration
MMU.6.2 Self Administration
– Patient self-administration of medications.
– The documentation and management of
any medications brought into the
organization for or by the patient.
– The availability and use of medication
samples.
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– PP are implemented to govern:
– Medication effects on patients are
monitored, including adverse effects
– The monitoring process is collaborative
– The organization has a policy that
identifies those adverse effects that are
to be recorded in the patient’s record
and those that must be reported to the
organization
Continued on next slide
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MMU.7 Monitoring
MMU.7 Monitoring
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– Adverse effects are documented in the
patient’s record as required by policy
– Adverse effects are reported in the time
frame required by policy
– A medication error and near-miss are defined
– Medication errors and near-misses are
reported in a timely manner using an
established process
– Those accountable for taking action on the
reports are identified
– The organization uses medication errors and
near-misses reporting information to improve
medication use processes.
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MMU.7.1 Medication Errors
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198
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Patient and Family Education
(PFE)
– The hospital plans education consistent
with its mission, services, and patient
population
– There is an appropriate structure or
mechanism for education throughout
the organization
– Education resources are organized in
an efficient and effective manner
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PFE.1 Patient Education
PFE.2 Needs Assessed
– How to participate in care decisions
– Their condition and any confirmed diagnosis
– Their right to participate in the care process as
appropriate
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– The educational needs of the patient and
family are assessed
– Education needs assessment findings are
recorded in the patient’s record
– There is uniform recording of patient
education by all staff
– Patients and families learn about:
PFE.2.1 Education Assessment
– The patient and family are assessed on:
The patient’s and family’s beliefs and values
Their literacy, educational level, and language
Emotional barriers and motivations
Physical and cognitive limitations
The patient’s willingness (formerly readiness) to
receive information
– The assessment findings are used to
plan the education and documented in
the patient’s medical record
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–
–
–
–
–
– Patients and families receive education and
training to meet their ongoing health needs or
achieve their health goals
– The organization identifies and establishes
relationships with community resources that
support continuing health promotion and
disease prevention education
– Patients are referred to these sources when
appropriate and available
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PFE.3 Ongoing Health Needs
PFE.4 Education Topics
– The safe and effective use of all medications and
potential side effects of medications
– Safely and effectively using medical equipment.
– Preventing interactions between prescribed
medications and other medications (including
non-prescription items) and food
– Appropriate diet and nutrition
– Pain management
– Rehabilitation techniques
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– When appropriate, patients and families are
educated about:
– Interaction among staff, the patient, and
family confirms that the information was
understood
– Those who provide education encourage
patients and their families to ask questions
and speak up as active participants
– Verbal information is reinforced with written
material as appropriate to the patient’s needs
and learning preferences
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PFE.5 Education Methods
– Patient and family education is provided
collaboratively when appropriate
– Those who provide education have the
subject knowledge to do so
– Those who provide education have
adequate time to do so
– Those who provide education have the
communication skills to do so
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PFE.6 Collaboration
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Quality Improvement and Patient
Safety (QPS)
1. Leadership and Planning
2. Design of New and Modified
Processes
3. Data Collection for Quality Monitoring
4. Analysis of Data
5. Process Improvement
6. Proactive Risk Reduction
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QPS - Six Areas of Focus
– The hospital’s leadership
– participates in developing the plan for the
quality improvement and patient safety
(QIPS) program
– participates in measuring the QIPS program
– establishes the oversight process or
mechanism for the hospital’s QIPS program
– reports on the QIPS program to Governance
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QPS.1 Leadership
– The hospital’s leaders collaborate to carry out the
QIPS program
– The QIPS program
– is organization-wide
– addresses the systems of the hospital and the role
of system design and redesign in quality and
safety improvement
– addresses coordination among all components of
the hospital’s quality monitoring and control
activities
– employs a systematic approach to quality
improvement and patient safety
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QPS.1.1 The Program
– The leaders set priorities for
– measurement activities
– improvement activities
– patient safety activities
– The priorities include the implementation of
the International Patient Safety Goals
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QPS.1.2 Priorities
– The leaders understand the technology
and other support requirements for
tracking and comparing monitoring
results
– The leaders provide technology and
support, consistent with the hospital’s
resources, for tracking and comparing
monitoring results
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QPS.1.3 Support
– Information on the QIPS program is
communicated to staff
– The communications are on a regular
basis through effective channels
– The communications include progress
on compliance with International Patient
Safety Goals
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QPS.1.4 Communication
– There is a training program for staff that
is consistent with their role in the QIPS
program
– A knowledgeable individual provides the
training
– Staff members participate in the training
as part of their regular work assignment
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QPS.1.5 Staff Training
– Quality improvement principles and tools are
applied to the design of new or modified
processes.
– Elements of Good Process Design are
considered when relevant to the process
being designed or modified.
– Indicators are selected to measure how well
the newly designed or redesigned process
operates.
– Indicator data are used to evaluate the
ongoing operation of the process.
See next slide for Good Process Design
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QPS.2 Process Design
a. Consistent with the organization’s mission and
plans
b. Meets the needs of patients, families, staff, and
others
c. Uses current practice guidelines, clinical standards,
scientific literature, and other relevant evidencebased information on clinical practice design
d. Consistent with sound business practices
e. Considers relevant risk management information
f. Builds on available knowledge and skills in the
organization
g. Builds on the best/better/good practices of other
organizations
h. Uses information from related improvement
activities
i. Integrates and connects processes
and systems
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Good Process Design
– Hospital and clinical leaders use
– clinical guidelines to guide patient care
processes
– clinical pathways to standardize care
processes
– The process is used to adapt, adopt or
update at least one guideline and one
pathway per 12 month period
See next page for CPG Process
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QPS.2.1 Clinical Guidelines and
Pathways
a. Selected from among those applicable to the services
and patients of the hospital
– Mandatory national guidelines, if any, are
implemented
b. Evaluated for their applicability and science
c. Adapted when needed to the technology, drugs and
other resources of the organization or to accepted
national professional norms
d. Formally approved or adopted by the hospital
e. Implemented and monitored for consistent use and
effectiveness
f. Supported by staff trained to apply the guidelines or
pathways
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g. Periodically updated
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Implementing Clinical Guidelines
and Pathways
– The leaders identify targeted areas for
measurement and improvement
– Measurement is part of quality improvement and
patient safety program
– Measurement results communicated to:
– Oversight mechanism
– Organizational leaders
– Governance structure
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QPS.3 Key Measures
–
–
–
–
–
–
–
–
–
–
Patient assessments
Laboratory services
Radiology and diagnostic imaging services
Surgical procedures
Antibiotic and other medication use
Anesthesia and sedation use
Use of blood and blood products
Patient record
Infection, prevention and control
Clinical research
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QPS.3.1 Clinical
Measurement
– Leaders identify key measures for each
clinical area
– At least 5 of the 11 measures are
selected from JCI Library of Measures
– Leaders look at the science and
evidence
Continued on next slide
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QPS.3.1 Clinical Measures
– Measurement includes structure,
processes and outcomes
– Scope, method and frequency are
identified for each measure
– Clinical measurement data are collected
and used to evaluate the effectiveness of
improvements
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QPS.3.1 Clinical Measures
– Procurement of routinely required supplies and
medications
– Reporting of activities as required by law and
regulations
– Risk management
– Utilization management
– Patient and family expectations and satisfaction
– Staff expectations and satisfaction
– Patient demographics and clinical diagnosis
– Financial management
– Prevention and control of events that jeopardize
the safety of patients, families and staff
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QPS.3.2 Managerial Measures
– Managerial leaders identify measures for
managerial areas
– Leaders look at the science or evidence
– Measurement includes structure, processes
and outcomes
– Scope, method and frequency are identified
for each measure
– Data are collected and used to evaluate
effectiveness of improvements
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QPS.3.2 Managerial Measures
QPS.3.3 Measures for IPSG
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– Clinical and managerial leaders identify
key measures for IPSG
– Measurement data are used to evaluate
effectiveness of improvement
– Data are aggregated, analyzed, and
transformed into useful information
– Individuals with appropriate clinical or
managerial experience, knowledge, and skills
participate in the process
– Statistical tools and techniques are used in
the analysis process when appropriate
– Results are reported to those accountable for
taking action
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QPS.4 Analysis of Data
QPS.4.1 Frequency of Data Analysis
– The frequency of data analysis:
– is appropriate to the process under study
– meets organization requirements
– Comparisons are made:
– Over time within the organization
– With similar organizations when possible
– With standards when appropriate
– With known desirable practices
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QPS.4.2 Data Comparisons
QPS.5 Data Validation
Continued on next slide
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– Hospital integrates data validation into
the quality management and
improvement program
– Data validation includes the measures
selected as required in QPS.3.1
– Internal validation includes:
– Re-collecting data by a second person
– Using statistically valid sample of records, cases
and data
– Comparing original data with re-collected data
– Calculating accuracy
– Noting unclear data and taking corrective actions
– Collecting new samples after corrective answers
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QPS.5 Data Validation
QPS.5.1 Published Data
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– Leaders assume accountability for
reliability of quality and outcome data
– Data made public have been evaluated
for reliability and validity
– Establish a definition of a sentinel event:
– Unanticipated death unrelated to the course
of illness
– Major permanent loss of function unrelated to
natural course of illness
– Wrong site, wrong procedure, wrong patient
– Infant abduction or infant sent home with
wrong parents
Continued on next slide
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QPS.6 Sentinel Events
– Conducts a Root Cause Analysis on all
sentinel events from previous slide
– Events are analyzed as they occur
– Leaders take action on results of Root
Cause Analysis
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QPS.6 Sentinel Events
QPD.7 Undesirable Trends
–
–
–
–
Transfusion reactions
Drug events
Medication errors
Major discrepancies in pre-op and post-op
diagnosis
– Moderate or deep sedation and anesthesia
– Other events defined by hospital
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– Intense analysis take place when adverse
levels, patterns and trends occur
– The hospital establishes a definition of a
near-miss
– Defines the type of events to be reported
– The hospital establishes the process for the
reporting of near- misses
– The data are analyzed and actions taken to
reduce near-miss events
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QPS.8 Near Misses
Definitions
Actual SE
Examples
Response
JCI can review RCA
Add to SE Database
SE
Policy
Patient death from medication
misadministration
"reviewable"
On-going data
collection
Significant
misadministration
-- patient survives
Adverse events
"Important single events"
Full range of events,
incidents, occurrences, etc.
Majority of
medication
errors
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Conduct RCA
Not subject to SE
definition
Evaluate process
at triennial survey
– Plan and implement improvements in
quality and safety
– Consistently identify priority
improvements selected by leaders
– Document improvements achieved and
sustained
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QPS.9 Improvement Activities
– Leaders identify priority areas
– Human or other resources are allocated
or assigned
– Changes are planned and tested
– Changes are implemented
– Data demonstrates effective and
sustained improvements
– Successful improvements are
documented
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QPS.10 Priority Areas
QPS.11 Identify and Reduce
Unanticipated Adverse Events
– Leaders adopt a framework that:
– Conducts and documents a pro-active risk
reduction annually
– Take action to redesign high-risk processes
based on analysis
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– Risk identification, prioritization, reporting,
management
– Investigation of adverse events
– Management of related claims
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Prevention and Control of
Infections (PCI)
PCI - Six Areas of Focus
Program Leadership and Coordination
Focus of the Program
Isolation Procedures
Barrier Techniques and Hand Hygiene
Integration of Program with Quality
Improvement and Patient Safety
6. Education of Staff About the Program
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1.
2.
3.
4.
5.
– One or more individuals oversee the
infection control program
– The individual(s) is/are qualified for the
organization’s size, level of risks, and
program scope and complexity
– The individual(s) fulfills program
oversight responsibilities as assigned or
described in a job description
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PCI.1 Oversight of Program
– There is a designated mechanism for the
coordination of the infection control program
– Coordination of infection control activities involves:
– Medicine
– Nursing
– Infection control professionals
– Housekeeping
– Others (as appropriate)
– (Note that a Committee is not required but most
hospitals find coordination easiest if there is one)
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PCI.2 Coordination of Activities
– The infection control program is based on:
– Current scientific knowledge
– Accepted practice guidelines
– Applicable law and regulation
– National standards or local agencies
–For sanitation and cleanliness
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PCI.3 Infection Control Program
– The infection control program is adequately
staffed as approved by the leadership
– The organization’s leaders allocate adequate
resources for the infection control program
– Information management systems support the
infection control program (an area highlighted
as needing special IT attention)
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PCI.4 Adequate Resources
– There is a comprehensive program and plan to
reduce the risk of health care-associated infections
– in patients
– in health care workers
– The program
– includes systematic and proactive surveillance
activities to determine usual (endemic) rates of
infection.
– includes systems to investigate outbreaks of
infectious diseases
– is guided by appropriate PP
Continued on next slide
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PCI.5 Comprehensive
Program
– Risk reduction goals and measurable
objectives are established and regularly
reviewed
– The program is appropriate to the hospital’s
size and geographic location, services, and
patients
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PCI.5 Comprehensive
Program
– All patient care areas of the hospital are
included in the infection control program
– All staff areas of the hospital are
included in the infection control program
– All visitor areas of the hospital are
included in the infection control program
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PCI.5.1 Areas Included
– The organization uses a risk based approach in
establishing the focus of the health care
associated infection prevention and reduction
program.
– Data evaluation/analysis actions are taken to
focus or refocus infection prevention and control
program
– Assess annually and document the assessment.
Continued next slide
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PCI.6 Focus of Program
– Organizations collect and evaluate data on
the following relevant infections and sites:
– Respiratory tract infections
– Urinary tract infections
– Intravascular invasive devices
– Surgical wounds
– Epidemiologically significant diseases and
organisms in the hospital & community
– Emerging or reemerging infections in the
hospital & community
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PCI.6 Focus of Program
– The hospital has identified those
processes associated with infection risk
– The hospital has implemented
strategies to reduce infection risk in
those processes
– The hospital identifies which risks
require policies and or procedures, staff
education, practice changes and other
activities to support risk reduction
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PCI.7 Risk Processes
– Equipment cleaning and sterilization
methods in and outside of the central
sterilization service are appropriate for the
type of equipment
– Laundry and linen management are
appropriate to minimize risk to staff and
patients
– There is a coordinated oversight process
for all cleaning, disinfection and
sterilization throughout the hospital
Continued next slide
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PCI.7.1
Equipment/Laundry/Sterilization
– Managing expired supplies and reuse of single
use devices
– Policy and procedure consistent with
national laws, regulations, and professional
standards for expired supplies
– When can single use devices be reused
– Implement and monitor the policy
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PCI.7.1.1
Equipment/Laundry/Sterilization
– Managing to minimize transmission risk of:
– Disposal of infectious waste and body
fluids
– Handling and disposal of blood and blood
components (including blood samples)
– Operation of the mortuary and postmortem
area
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PCI.7.2 Waste Disposal
– Sharps and needles are collected in
dedicated, puncture-proof containers which
are not re-used (and not overfilled)
– The hospital disposes of sharps and needles
safely or contracts with sources that ensure
the sharps containers are disposed of in
dedicated hazardous waste sites or by an
appropriate process
– The disposal of sharps and needles is
consistent with infection control policies of the
hospital
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PCI.7.3 Sharps and Needles
– Kitchen sanitation and food preparation and
handling are appropriate to minimize
infection risk
– Engineering controls are implemented as
appropriate to minimize infection risk in
appropriate areas of the organization
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PCI.7.4 Food Service & Engineering
PCI.7.5 Construction &
Renovation
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– The hospital uses risk criteria to assess the
impact of renovation or new construction
– The risks and impact of the renovation or
construction on air quality and infection
control activities is assessed and managed
– Patients with known contagious diseases are
isolated in accordance with hospital policy
and recommended guidelines
– PP address the separation of patients with
communicable diseases from patients and
staff who are at greater risk due to immunosuppression or other reasons
Continued next slide
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PCI.8 Barrier Precautions
– The hospital has a strategy of dealing with an
influx of patients with contagious diseases
– Appropriate negative pressure rooms are
available and monitored routinely for
infectious patients that require isolation
– Staff is educated in the management of
infectious patients
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PCI.8 Barrier Precautions
– The hospital identifies those situations for which gloves
and/or masks or eye protection are required
– Gloves and/or masks or eye protection are correctly
used in those situations
– The hospital identifies those areas where hand washing
and hand disinfection or surface disinfecting procedures
are required
– Hand washing and hand disinfection procedures are
used correctly in those areas
– The hospital has adopted hand hygiene guidelines from
an authoritative source
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PCI.9 Gloves, Masks, Eye Protection
– Infection control activities are integrated
into the hospital’s quality improvement
and patient safety program
– The leadership of the infection control
program is included in the hospital’s
quality and patient safety program’s
oversight mechanism
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PCI.10 Quality Integration
– Health care-associated infection risks
are tracked
– Health care-associated infection rates
are tracked
– Health care-associated infection trends
are tracked
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PCI.10.1 Risks, Rates, & Trends
PCI.10.2 Important Measures
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– Infection prevention and control
activities are measured
– The measures identify epidemiologically
important infections
– Processes are redesigned based on
risk, rate, and trend data and
information
– Processes are redesigned to reduce
infection risk to the lowest levels
possible
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PCI.10.3 Process Redesign
PCI.10.4 Comparisons
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– Health care-associated infection rates
are compared to other organizations’
rates through comparative databases
– The organization compares its rates to
best practices and scientific evidence
PCI.10.5 Communication of
Monitoring Results
– medical staff
– nursing staff
– management
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– Monitoring results are communicated
to the following:
PCI.10.6 Reporting to Outside
Agencies
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– The organization takes appropriate action on
reports from relevant public health agencies
– Infection control program results are reported
to public health agencies as required
– The organization provides education
about infection control
– Clinical staff and other professional staff
are included in the program
– Patients and families are included when
appropriate to the patient’s needs and
condition
Continued on next slide
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PCI.11 Education
– All staff is oriented to the policies,
procedures, and practices of the infection
control program
– Periodic staff education includes new policies
and procedures
– Periodic staff education is in response to
significant trends in infection data
– Patients and families are encouraged to
participate in the infection control program
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PCI.11 Education
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Governance, Leadership, and
Direction (GLD)
1. Governance of the Organization
2. Leadership of the Organization
3. Direction of Departments and
Services
4. Organizational Ethics
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GLD - Four Areas of Focus
– The organization’s governance structure is
described in written documents
– Governance responsibilities and
accountabilities are described in the
documents
– The documents describe how the
performance of the governing entity and
managers will be evaluated and any related
criteria
– There has been one documented
performance evaluation of governance
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GLD.1 Governance
– Those responsible for governance
– approve the organization’s mission
– ensure the periodic review of the
organization’s mission
– make public the organization’s
mission
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GLD.1.1 Mission
– Those responsible for governance approve the
organization’s:
– Strategic and management plans
– Operating policies and procedures
– When approval authority is delegated it is defined in
governance polices and procedures
– Those responsible for governance approve
organization strategies and programs related to health
care professional education and research and then
provide oversight of the quality of such programs
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GLD.1.2 Operational Responsibilities
– Those responsible for governance
– approve the organization’s capital and
operating budgets
– allocate the resources required to
meet the organization’s mission
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GLD.1.3 Budget
– Those responsible for governance
– appoint the organization’s senior
manager
– evaluate the performance of the
organization’s senior manager
annually
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GLD.1.4 Appoint Senior Management
and Directors
GLD.1.5 Reports of Quality and
Patient Safety
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– Approval of the organizational plan for
quality and patient safety
– Receive and act on reports of the
quality and patient safety program
GLD.2 Senior Leader
– Manages the organization’s day-to-day
operations
– Has the education and experience to carry out
his or her responsibilities
– Recommends policies to the governing body
– Ensures compliance with approved policies
– Ensures compliance with applicable law and
regulation
– Responds to any reports from inspecting and
regulatory agencies
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– The senior manager or director:
– The leaders of the hospital are formally or
informally identified
– The leaders are collectively responsible
– for defining the hospital’s mission
– creating the PP necessary to carry out the
mission
– The leaders work collaboratively to carry out
the organization’s mission and ensure that PP
are followed
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GLD.3 Hospital Leaders
– The hospital’s leaders
– plan with recognized community leaders
– plan with the leaders of other provider
organizations in its community
– seek the input of individual and group
stakeholders in its community as part of its
strategic and operational planning
– The organization participates in community
education on health promotion and disease
prevention
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GLD.3.1 Leadership Planning
– Organization plans describe the care and services to
be provided
– The care and services to be offered are consistent
with the organization’s mission
– Clinical leaders
– determine the type of care and services to be
provided by the organization
– have a process for reviewing and approving,
before use in patient care, those procedures,
technology and pharmaceutical agents considered
experimental
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GLD.3.2 Clinical Leaders
– The organization identifies recommendations
of professional organizations and other
authoritative sources in relation to the
equipment and supplies needed to provide
services
– Recommended equipment, supplies and
medications are
– obtained as appropriate
– Used as appropriate
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GLD.3.2.1 Equipment and Supplies
– There is a process for leadership oversight of
contracts
– There is a written description of services
provided by contractual agreements
– Services provided under contracts and other
arrangements meet patient needs
– Clinical and managerial leaders participate in
selection of clinical contracts and are
accountable
– Patient services are maintained when
contracts are negotiated and terminated
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GLD.3.3 Contracts
– Contracts and other arrangements are
evaluated as part of the quality and
patient safety program
– Clinical and manager leaders participate
– Action is taken when contracted
services do not meet quality and patient
safety expectations
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GLD.3.3.1 Contracts and Quality
Improvement
– Leaders determine services provided by
independent practitioners (IP) outside the
organization
– Diagnostic, consultative, and other treatment
services provided by IP are privileged
– IP not employed or members of the clinical
staff are credentialed and privileged
– Quality of services by IP is monitored
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GLD.3.3.2 Independent
Practitioners
– Medical, nursing, and other clinical leaders:
– Are educated in or are familiar with the
concepts and methods of quality
improvement
– Participate in relevant quality improvement
and patient safety processes
– Professional performance is monitored as part
of clinical monitoring
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GLD.3.4 QI Concepts
– There is a planned process for staff
recruitment and retention
– There is a planned process for staff personal
development and continuing education
– The planning is collaborative and includes all
departments and services in the organization
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GLD.3.5 Recruitment and Retention
– There is an (are) effective organizational structure(s)
used by medical, nursing, and other clinical leaders
to carry out their responsibilities and authority
– The structure(s) is (are) appropriate to the
organization’s size and complexity
– The organizational structure(s) and processes
– support professional communication
– support clinical planning and policy development
– support oversight of professional ethical issues
– support oversight of the quality of clinical services
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GLD.4 Structures
– An individual with appropriate training,
education, and experience directs each
department or service in the
organization
– When more than one individual provides
direction, the responsibilities of each are
defined in writing
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GLD.5 Department Directors
– Department or service directors have
selected and use a uniform format and
content for planning documents
– Departmental or service documents describe
the current and planned services provided by
each department or service
– Each department’s or service’s PP
– guide the provision of identified services
– address the staff knowledge and skills
needed to assess and meet patient needs
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GLD.5.1 Departments/Services
– There is coordination and integration of
services within each department or
service
– There is coordination and integration of
services with other departments and
services
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GLD.5.1.1 Coordination & Integration
– Department and service directors recommend
– space needed to provide services
– equipment needed to provide services
– the number and qualifications of staff needed
to provide services
– other special resources needed to provide
services
– Department and service directors have a
process to respond to resource shortages
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GLD.5.2 Directors’ Role
– The director develops criteria related to
the needed education, skills, knowledge
and experience of the department’s
professional staff
– The director uses such criteria in
selecting or recommending professional
staff
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Gld.5.3 Staff Selection Criteria
GLD.5.4 Orientation
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– The director has established an
orientation program for department staff
– All department staff has completed the
program
– Directors implement quality monitors that address the
services provided in their department or service using the
following criteria:
– The organization’s monitoring and improvement
priorities that relate to the department or service
– The evaluation of the provided services, from sources
including patient surveys and complaints
– The need to understand the efficiency and cost
effectiveness of the services provided
– Contractual arrangements
– Quality control programs when indicated
Continued
onPresentation
next slide
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GLD.5.5 Departmental Monitors
– Department or service directors are
provided the data and information
needed to manage and improve care
and services
– Department and service quality
monitoring and improvement activities
are reported periodically to the quality
oversight mechanism of the organization
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GLD.5.5 Departmental Monitors
– Organization leaders establish ethical
and legal norms that protect patients
and their rights
– The leaders establish a framework for
the organization’s ethical management
– Leaders consider national and
international ethical norms when
developing ethical framework
Continued on next slide
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GLD.6 Ethical Management
– International documents intended to shape ethical
norms:
– Universal Declaration of Human Rights
– Geneva Conventions
– Declaration of Tokyo: Guidelines for Physicians
Concerning Torture and Other Cruel, Inhuman or
Degrading Treatment or Punishment in Relation to
Detention and Imprisonment
– Oath of Athens
– International Covenant on Civil and Political Rights
– Convention Against Torture and Other Cruel,
Inhuman or Degrading Treatment of Punishment
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GLD.6 Ethical Management
– The organization
– discloses its ownership.
– honestly portrays its services to patients
– provides clear admission, transfer, and
discharge policies
– accurately bills for services
– discloses and resolves conflicts when
financial incentives and payment
arrangements compromise patient care
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GLD.6.1 Ethical Framework
– The organization’s framework for ethical
management supports those confronted
by ethical dilemmas in patient care and
non-clinical services
– The support is readily available
– Allows for safe reporting of ethical and
legal concerns
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GLD.6.2 Support for Ethical
Dilemmas
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Facility Management (FMS)
1.
2.
3.
4.
5.
6.
7.
Leadership and Planning
Safety and Security
Hazardous Materials
Disaster Preparedness
Medical Equipment
Utility Systems
Staff Education
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FMS - Eight Areas of Focus
– The hospital’s leaders
– know what laws, regulations, and other
requirements apply to the hospital’s
facilities
– implement the applicable requirements or
approved alternatives
– ensure that the hospital meets the
conditions of facility inspection reports or
citations
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FMS.1 Laws and Regulations
There are written plans that address the risk
areas for:
– Safety and Security
– Safety - The degree to which the
organization’s buildings, grounds and
equipment do not pose a hazard or risk to
patients, staff, visitors
– Security – Protection from loss,
destruction, tampering, or unauthorized
access or use
Continued on next slide
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FMS.2 Plans
– Other required plans
– Hazardous Materials– Handling, storage, and use
of radioactive and other materials are controlled,
and hazardous waste is safely disposed
– Emergencies – Response to epidemics, disasters,
and emergencies is planned and effective
– Fire safety – Property and occupants are
protected from fire and smoke
– Medical equipment – Equipment is selected,
maintained, and used in a manner to reduce risks
– Utility systems – Electrical, water, and other utility
systems are maintained to minimize the risks of
operating failures
Continued on next slide
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FMS.2 Plans
– The plans are current or up-to-date
– Current means no older a year (see below)
– The plans are
– fully implemented
– reviewed and updated at least on an
annual basis
– (having six separate plans is not required.
There may be a fewer number of documents
as long as they cover the respective areas
adequately, in accordance with Standards)
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FMS.2 Plans
– Program oversight and direction are assigned to one or
more individuals, qualified by experience or training
– The individual(s) plans and implements the program
including:
a) planning all aspects of the program
b) implementing the program
c) educating staff
d) testing and monitoring the program
e) periodically reviewing and revising the program
f) annual reports to the governing body on the
effectiveness of the program
g) providing consistent and continuous organization
and management
Continued on next slide
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FMS.3 Program Oversight
FMS.3.1 Monitoring Program
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– There is a program to monitor all
aspects of the facility/environment risk
management program
– Monitoring data are used to improve the
program
– The hospital has a program to provide a safe and
secure physical facility
– The program
– ensures that all staff, visitors and vendors are
identified and all security risk areas are monitored
and kept secure
– is effective in preventing injury and maintaining
safe conditions for patients, families, staff, and
visitors
– includes safety and security during times of
construction and renovation
– The leaders apply resources in accordance with
approved plans
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FMS.4 Safe and Secure
– The hospital has a documented, current,
accurate inspection of its physical facilities
– (Current means less than a year old)
– The hospital has a plan to reduce evident
risks based on the inspection
– (“Evident risks” are those cited in the
inspection report)
– The hospital is making progress in carrying
out the plan
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FMS.4.1 Facility Inspection
– The hospital plans and budgets
– to meet applicable laws, regulations, and
other requirements
– for upgrading or replacing systems,
buildings, or components needed for the
continued operation of a safe and effective
facility
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FMS.4.2 Budgeting
– The hospital identifies hazardous materials and
waste and has a current list of all such materials
within the organization
– Includes at least chemicals, Chemotherapy
agents, radioactive materials and waste,
hazardous gases and vapors, and other
regulated medical and infectious waste (see
Intent Statement)
– The plan identifies documentation requirements
including any permits, licenses, or other
regulatory requirements
Continued
on next slide
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FMS.5 Hazardous Materials
– The plan includes
– safe handling, storage, and use
– reporting and investigation of spills,
exposures, and other incidents
– the proper handling of waste within the
hospital and disposal of hazardous waste
in a safe and legal manor
– the proper protective equipment and
procedures during use, spill, or exposure
– labeling hazardous materials and waste
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FMS.5 Hazardous Materials
– The hospital has identified the major internal
and external disasters and major epidemic
events which pose significant risks of
occurring
– The hospital plans its response to likely
disasters including determining the type,
likelihood and consequences of events
Continued on next slide
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FMS.6 Disaster Preparedness
– The Emergency Management Plan also
includes:
–the hospital’s role
–communication strategies
–the managing of resources including
alternative sources
–the managing of clinical activities including
alternative care sites
–the identification and assignment of staff
roles and responsibilities
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FMS.6 Disaster Preparedness
FMS.6.1 Testing the Emergency Plan
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– The Emergency Plan is tested annually
– A debriefing occurs after the test
– Any independent entities within patient
care facilities comply with the plan
– The hospital plans a program to ensure that
all occupants of its facilities are safe from fire,
smoke, or other non-fire emergencies
– (“Internal Disasters”)
– The program is implemented in a continuous
and comprehensive manner to ensure that all
patient care and staff work areas are included
– Any independent entities within patient care
facilities comply with the plan
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FMS.7 Fire Safety
– The program includes:
– the reduction of fire risks
– the early detection of fire and smoke
– the abatement of fire and containment of
smoke
– the safe exit from the facility when fire and
non-fire emergencies occur
– the assessment of fire risks when
construction is present in or adjacent to the
facility
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FMS.7.1 Fire Safety Program
– Fire detection and abatement systems are
inspected, tested, and maintained at a
frequency determined by the organization
– The fire and smoke safety evacuation plan is
tested at least twice a year
– Staff is trained to participate in the fire and
smoke safety plan
– Staff participates in at least one fire and
smoke safety test per year
– Inspection, testing, and maintenance of
equipment and systems are documented
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FMS.7.2 Testing Fire Plan
– The hospital has developed and implemented
a policy and plan to eliminate or limit smoking
– Eliminates it altogether, or limits it to
specified non-clinical areas, vented to
outside (See Intent Statement)
– The plan applies to patients, families, visitors,
and staff
– There is a process to grant patient exceptions
to the plan
– (e.g. psychiatric patients, selected others)
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FMS.7.3 Smoking
– Medical equipment is managed throughout
the hospital according to a plan
– There is an inventory of all medical
equipment
– Medical equipment is regularly inspected
– Medical equipment is tested when new and
as appropriate thereafter
– (Testing for safety)
– There is a preventive maintenance program
– Qualified individuals provide these services
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FMS.8 Medical Equipment
– Monitoring data are collected and
documented for the medical
equipment management program
– Monitoring data are used for purposes
of planning and improvement
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FMS.8.1 Monitoring of Equipment
– There is a product/equipment recall
system in place
– Policy or procedure addresses any use
of any product or equipment under
recall
– The policy or procedure is implemented
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FMS.8.2 Recall System
FMS.9 Drinking Water and Electrical
Power
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– Potable water is available 24 hours a
day, seven days a week
– Electrical power is available 24 hours a
day, seven days a week
FMS.9.1 Backup for Failure
FMS.9.2 Testing of Supply
The hospital
regularly tests alternate sources of water and
electricity annually
- documents the results of such tests
-
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– The hospital
– has identified the areas and services at greatest
risk when power fails or water is contaminated or
interrupted
– seeks to reduce the risks of such events
– plans alternate sources of power and water in
emergencies
– Utility, medical gas, ventilation and other key
systems are identified by the organization
– Key systems are:
– Regularly inspected
– Regularly tested
– Regularly maintained
– Improved when necessary
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FMS.10 Testing of Systems
– Water quality is monitored regularly
– Chemical and biological
– Interval to be determined
– Water used in chronic renal dialysis is
tested regularly
– Chemical and biological
– Interval to be determined
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FMS.10.1 Water Testing
– Monitoring data are
– collected and documented for
the medical utility management
program
– used for purposes of planning
and improvement
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FMS.10.2 Monitoring Data
– For each component of the organization’s
facility management and safety program,
there is planned education to ensure that staff
members can effectively carry out their
responsibilities
– The education includes visitors, vendors,
contract workers, and others as appropriate
to the organization and multiple shifts of staff
– What kind of education for each group?
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FMS.11 Education for Staff and
Others
– Staff members can describe and/or
demonstrate
– their role in response to a fire
– actions to eliminate, minimize, or report
safety, security, and other risks
– precautions, procedures, and participation
in the storage, handling, and disposal of
medical gases, hazardous waste and
materials and in related emergencies
– procedures and their role in internal and
community emergencies and disasters
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FMS.11.1 Staff Knowledge
FMS.11.2 Medical Equipment
Training
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– Staff is trained to operate and maintain
medical equipment appropriate to their
job requirements
– Staff knowledge is tested regarding
their role in maintaining a safe and
effective facility
– Staff training and testing are
documented as to who was trained
and tested and the results
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FMS.11.3 Testing Staff Knowledge
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Next Presentation
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Staff Qualifications and
Education (SQE)
1.
2.
3.
4.
5.
Planning
Orientation and Education
Medical Staff
Nursing Staff
Other Professional Staff
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SQE - Six Areas of Focus
– The organization’s mission, mix of
patients, services, and technology are
considered in planning
– The desired education, skills, and
knowledge are defined for staff
– Applicable laws and regulations are
incorporated into the planning.
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SQE.1 Leaders Plan for Staff
– Each staff member who is not permitted
to practice independently has a job
description
– Job descriptions are current according
to hospital policy (hospital has to define
“current”)
Continued on next slide
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SQE.1.1 Job Descriptions
– A job description is also needed when someone
– serves in primarily a managerial role,
–(as in dual clinical and managerial roles, the
managerial responsibilities are in a job
description)
– has some clinical responsibilities, for which
they have not been authorized to practice
independently
–(as an independent practitioner learning
new skills)
Continued
on Presentation
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SQE.1.1 Job Descriptions
– There are also job descriptions for all
who
– are in an educational program and for
each level of training, what can be
done independently and what must be
under supervision. (The program
description can be the job description)
– are permitted to temporarily provide
services in the organization
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SQE.1.1 Job Descriptions
– There is a process in place to:
– Recruit staff
– Evaluate the qualifications of new staff
– Appoint individuals to the staff
– The process is uniform across the
organization
– The process is implemented
Client name/ Presentation Name/ 12pt - 342
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SQE.2 Recruitment
– The hospital uses a defined process to
match clinical staff knowledge and skills
with patient needs
– New clinical staff members are
evaluated at the time they begin their
work
– The individuals department or service
conducts the evaluation
Continue on next slide
Client name/ Presentation Name/ 12pt - 343
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SQE.3 Clinical Staff Evaluation
– The hospital defines the frequency of
ongoing clinical staff evaluation, but
– There is at least one documented
evaluation of each clinical staff member
working under a job description each
year or more frequently as defined by
the hospital
Client name/ Presentation Name/ 12pt - 344
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SQE.3 Clinical Staff Evaluation
– The hospital uses a defined process to
match non-clinical staff knowledge and
skills with the requirements of the
position
– New non-clinical staff are evaluated at
the time they begin their work
responsibilities
– The department or service conducts the
evaluation
Continue on next slide
Client name/ Presentation Name/ 12pt - 345
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SQE.4 Non-Clinical Staff Evaluation
– The hospital defines the frequency of
ongoing non-clinical staff evaluation, but
– There is at least one documented
evaluation of non-clinical staff members
each year or more frequently as defined
by the hospital.
Client name/ Presentation Name/ 12pt - 346
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SQE.4 Non-Clinical Staff Evaluation
– Personnel information is maintained for each
staff member
– Personnel files contain:
– Qualifications of the staff member
– Job description of staff member
– Work history of the staff member
– Results of evaluations
– Record of in-service education attended
– Personnel files are standardized and kept
current
Client name/ Presentation Name/ 12pt - 347
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SQE.5 Personnel Files
– There is a written plan for staffing the
organization
– The clinical and managerial leaders
developed the plan collaboratively
– The number, types, and desired
qualifications of staff are identified in the plan
using a recognized staffing method
– The plan addresses the assignment and
reassignment of staff
– The plan addresses the transfer of
responsibility from one individual to another.
Client name/ Presentation Name/ 12pt - 348
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SQE.6 Staffing Plan
SQE.6.1 Updating the Staffing Plan
Client name/ Presentation Name/ 12pt - 349
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– The effectiveness of the staffing plan is
monitored on an ongoing basis
– The plan is revised and updated when
necessary
– All new clinical and non-clinical staff
members, contract workers and
volunteers are oriented to:
– the organization
– the department or unit to which they
are assigned
– their job responsibilities and any
specific assignments
Client name/ Presentation Name/ 12pt - 350
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SQE.7 Orientation
– The hospital uses various sources of data
and information, including the results of
quality and safety monitoring, to identify staff
education needs
– Education programs are planned based on
these data and information
– Staff are provided ongoing in-service
education and training
– The education is relevant to each staff
member’s ability to meet patient needs,
and/or continuing education requirements
Client name/ Presentation Name/ 12pt - 351
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SQE.8 In-Service Education
– Staff members who provide patient care and
other staff who are identified by the hospital
are trained in cardiac life support
– The appropriate level of training (basic or
advanced) is provided with sufficient
frequency to meet staff needs
– There is evidence to show if a staff member
passed the training
– The desired level of training for each
individual is repeated every two years
Client name/ Presentation Name/ 12pt - 352
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SQE.8.1 Resuscitation
Techniques
– The hospital provides facilities and
equipment for staff in-service education
and training
– The hospital provides adequate time for
all staff to participate in relevant
education and training opportunities
Client name/ Presentation Name/ 12pt - 353
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SQE.8.2 Facilities and Time
SQE.8.3 Health Professional
Education
Continue
onPresentation
next slide
Client name/
Name/ 12pt - 354
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– Relevant to medical students, nursing students,
other health professional students
– Also relevant to post-graduate education (interns,
residents)
– The hospital
– provides a mechanism(s) for oversight of the
training program(s)
– obtains and accepts the parameters of the
sponsoring academic program
– has a complete record of all trainees
– The hospital
– has documentation of the enrollment
status, licensure or certifications achieved,
and academic classification of the trainees
– understands and provides the required
level of supervision for each type and level
of trainee
– integrates trainees into its orientation,
quality, patient safety, infection control and
other programs
Client name/ Presentation Name/ 12pt - 355
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SQE.8.3 Health Professional
Education
– The hospital’s leaders and staff plan the
health and safety program
– The program is responsive to urgent
and non-urgent staff needs through
direct treatment and referral
– Program data is provided to the
hospital’s quality and safety program
Continue on next slide
Client name/ Presentation Name/ 12pt - 356
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SQE.8.4 Staff Health & Safety
– There is a policy on the provision of
staff vaccinations and immunizations
– There is a policy on the evaluation,
counseling, and follow up of staff
exposed to infectious diseases, that is
coordinated with the infection
prevention and control program
Client name/ Presentation Name/ 12pt - 357
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SQE.8.4 Staff Health & Safety
358
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Credentialing and Privileging
of Professionals
– "credentialing:” “The process of obtaining,
verifying, and assessing the qualifications of a
health care practitioner. The process
determines if an individual can provide patient
care services in or for a health care
organization or network...”
– “credentials:” “Evidence of competence,
current and relevant licensure, education,
training, and experience.”
Client name/ Presentation Name/ 12pt - 359
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What is Credentialing?
– Those permitted by law, regulation, and the
organization to provide patient care without
supervision are identified
– There is a separate record of the credentials of
every medical staff member that contains copies
of any required license, certification, or
registration and other documents required
– Licensure, certification or registrations are
– Current
– Documented
– Verified from primary source
Client name/ Presentation Name/ 12pt - 360
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SQE.9 Medical Staff Credentialing
– Understand laws & regulations about
employing professionals
– Gather all available credentials,
including at least those required
– Verify from the original source every
piece of evidence submitted by the
candidate in support of his/her
credentials.
Client name/ Presentation Name/ 12pt - 361
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Intent of the Standard
– Potential for falsified credentials
– U.S. experience (small percentage of
falsification, but frequent moves from
State to State by some)
– Australian experience (Dr. Patel)
– Indian experience (“quackery”)
– Singapore, UAE
Client name/ Presentation Name/ 12pt - 362
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Why Is Credentialing an Issue?
1.Those permitted by law, regulation, and the
organization to provide patient care without
supervision are identified
2.Licensure, education and training are
documented and verified from the primary
(original) source of the document
3 . All credentials are verified at the source before
the individual provides services for patients
4. Licensure, certification or registrations are
current
Client name/ Presentation Name/ 12pt - 363
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Some Measurable Elements of
Standard SQE.9
– Means the entity that issued the
document (license, certificate, or
reference)
– Means that the candidate cannot be
part of the chain of transmission of the
information from the original source of
that information to the hospital
Client name/ Presentation Name/ 12pt - 364
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The Original Source
– By letter
– By fax
– By telephone call (originating from the
hospital, not the source)
– Websites as Original Source
Client name/ Presentation Name/ 12pt - 365
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How Can the Original Source Be
Reached?
How to Document Original
Source Verification?
– Copies of letters sent and received
– Notes of telephone calls made with, date and
substance of call and identity of person making
the call and the one responding.
– Copies of web pages downloaded with date on
which accessed and name of person who
accessed it
Client name/ Presentation Name/ 12pt - 366
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– Each physician’s file contains:
Is There a Way Around This?
– There are three acceptable substitutes for an
organization performing primary source
verification of credentials
Client name/ Presentation Name/ 12pt - 367
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– Original source verification is always required;
however it does not always have to be
performed by the hospital
– Government
– Other hospitals in a hospital chain
– The credentials have been verified by an
independent third party such as a designated,
official governmental or non-governmental
agency and the hospital evaluates the agency
providing the information initially and then
periodically as appropriate (see criteria in
Intent Statement))
– Also known as Credentials Verification
Organizations (CVOs)
Client name/ Presentation Name/ 12pt - 368
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Alternatives to Hospitals Doing
Original Source Verification
What If One Cannot Get Blood
from a Turnip?
– it has closed
– its records have been destroyed
– whatever other reason
– When verification is not possible, the effort is
documented
Client name/ Presentation Name/ 12pt - 369
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– Original Source Verification is required by the
standard
– But sometimes is it simply not possible to get
a University to answer, because
– There is a standardized procedure to review
each record at least every three years
– At initial appointment and at least every three
years, a determination is made about the
current qualification of the individual to
provide patient care services
– Qualifications may be time limited
– License and registration
– Specialty qualifications
Client name/ Presentation Name/ 12pt - 370
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Still More SQE.9
Credentialing Review
– There is a standardized procedure to grant
privileges to practitioners on initial
appointment and on reappointment
– The procedure is documented in policies, is
followed, and can be demonstrated as to how
privileging decisions are reached
– The procedure considers sources of
information as relevant to the practitioner
Client name/ Presentation Name/ 12pt - 371
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SQE.10 Medical Staff Privileges
Resources to Support Requested
Privileges
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– Step I: Is this a service our organization will offer?
– Process to determine resources are in place (before
deciding which privileges to grant):
– Space, Equipment, Staffing, Financial resources
– Step II: Where will the services happen in our
organization?
– Privileges can be granted only at a certain site, clinic
or building where organization will provide services
– Step III: What are the criteria a doctor will have to meet?
– Step IV: Does the doctor’s application show evidence
that he meets the criteria
KEY: Must have a standardized,
Client name/ Presentation Name/ 12pt - 372
evidence-based procedure!
– SQE.10 ME 1 and 2: The decision to grant or deny a
privilege(s), and/or to renew an existing privilege(s), is
based on an objective, evidence-based process
(documented in policy).
– This means that processes are in place for:
– Developing and approving clinical privilege list
– Processing application
– Determining if sufficient clinical performance
information is available to make a decision
– If not, it may be a good idea to collect data on
outcomes for time-limited period of privilege-specific
monitoring (Focused Professional Evaluation – not
required by the standard)
Client name/ Presentation Name/ 12pt - 373
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Privileging Is an
Evidence-based Process
Recommendations –
What to Look for
–
–
–
–
–
Technical and clinical skills
Clinical judgment
Interpersonal skills
Communication skills
Professionalism
Client name/ Presentation Name/ 12pt - 374
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– Recommendations should include verification
from peers knowledgeable about the
practitioner’s professional performance
– Information to seek:
– Medical/Clinical knowledge
“Core vs. Special” Privileges
– Issue: What does “core” mean?
– What is generally meant by “core”?
– What must be part of any group or set of
privileges?
– Must be defined what task/activity/privilege
listed/specified can be performed
– Must be able to assess the practitioner’s ability to
perform each privilege, cannot be assumed
Client name/ Presentation Name/ 12pt - 375
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– Groupings of clinical privileges
– Specificity of “group” varies widely (part of
problem)
Level I
– Basic ambulatory care
Level II
– Level I services PLUS:
– Admit adult patients into inpatient status in non-critical settings;
– Perform admission history and physical examination
Level III
– Level II services PLUS:
– Admit or transfer patients into critical care settings and act as
attending physician for them, with consultation by appropriate
specialists (intensivist, cardiologist, etc.)
Level IV
– Level III services PLUS:
– Act as consultant in a particular subspecialty in internal medicine
and perform specialty procedures, listed separately.
Client name/ Presentation Name/ 12pt - 376
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Levels of Privileges
– WHO: There is no requirement who is to
make the decision, as long as it is
consistent with policy
– HOW: Each privilege specifically
requested should be separately
evaluated and “yes” or “no” decision
given
– Special case: “yes under supervision”
Client name/ Presentation Name/ 12pt - 377
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The Decision Process
– The privileges authorized for each medical
staff member are made known to appropriate
individuals and units of the organization and
are current
– In writing
– By electronic means
Client name/ Presentation Name/ 12pt - 378
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Communication of Privileges
–
On reappointment, every three years, the
organization seeks and uses information in
the following general competency areas of
all clinical practitioners:
– Patient care
– Medical/clinical knowledge
– Practice-based learning and improvement
– Interpersonal and communication skills
– Professionalism
– System-based practices
Client name/ Presentation Name/ 12pt - 379
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Medical Staff Credentials and
Privileges Review
– The organization has a
standardized procedure to gather
the credentials of each nursing staff
member
– Licensure, education, training, and
experience are documented
– Such information is verified from the
original source according to the
parameters found in the intent
statement of the standard that
describes physician credentialing.
Client name/ Presentation Name/ 12pt - 380
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SQE.12 Nursing Staff Credentials
In Other Words
– Nurses’ credentials have to be verified exactly
the same way as physicians’ credentials
– Because they are subject to the same kind
of tampering and
– because an unqualified nurse can do as much
harm to a patient as an unqualified doctor
Client name/ Presentation Name/ 12pt - 381
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Why?
Contract (Agency) Nurses
Client name/ Presentation Name/ 12pt - 382
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– The organization has a process to assure
that the credentials of contract nurses are
valid and complete prior to assignment
Special Problems with Verification of
Nursing Credentials
– Some countries issue nursing licenses based
on university diploma only
– Still need to verify the license
– The standards require that no one without a
license be allowed to perform tasks reserved for
licensed persons
– Not too many websites yet (are there any?)
Client name/ Presentation Name/ 12pt - 383
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– In some countries, expatriate nurses may
have to wait up to six months for a license
SQE.15 Other Professionals
– The organization has a standardized procedure
to gather the credentials of each allied health
professional staff member
– Licensure, education, training, and experience
are documented when relevant
– Such information is verified from the original
source according to the parameters found in the
intent statement of the standard that
describes physician credentialing.
Client name/ Presentation Name/ 12pt - 384
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– In most countries, not all allied health professionals
are licensed
Special Problems with Verification of
Other Professionals’ Credentials
Then why require it?
– There is evidence that false credentials in this
group are more frequent than in the other two
– May be as much as five times as common as
false medical credentials
Client name/ Presentation Name/ 12pt - 385
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– No uniformity of education or licensing laws
from one type of professional to the next
– No experience by hospitals in doing this kind
of work for other professionals
Client name/ Presentation Name/ 12pt - 386
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Next Presentation
387
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Management of Communication and
Information (MCI)
1.
2.
3.
4.
5.
6.
Communication with the Community
Communication with Patients and Families
Communication Between Providers Within
and Outside the Organization
Leadership and Planning
Patient Clinical Record
Aggregate Data and Information
Client name/ Presentation Name/ 12pt - 388
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MCI – Six Areas of Focus
– The hospital has
– identified its communities and populations
of interest
– implemented a communication strategy
with these populations
– The hospital provides information to the
community
– on its services, hours of operation
– on the process to obtain care
– on the quality of its services
Client name/ Presentation Name/ 12pt - 389
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MCI.1 Community Communication
– Patients and families are given
information on:
– The care and services provided by the
hospital
– How to access services in the hospital
– Alternative sources of care and
services when the hospital cannot
provide the care or services
Client name/ Presentation Name/ 12pt - 390
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MCI.2 Patient and Family Information
– Patient and family communication
and education are:
– In an understandable format
– Provided in an understandable
language
Client name/ Presentation Name/ 12pt - 391
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MCI.3 Communication and Education
– The leaders ensure processes are in place for
communicating relevant information within and
throughout the hospital in a timely manner
– The leaders communicate the hospital’s
mission and appropriate policies, plans, and
goals to all staff
– Effective communication occurs:
– In the hospital among the hospital’s
programs
– With outside organizations
– With patients and familiesClient name/ Presentation Name/ 12pt - 392
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MCI.4 Effective Communication
– Leaders ensure effective and efficient
communication among clinical and nonclinical departments, services, and
individual staff members
– Leaders foster communication in the
delivery of clinical services
Client name/ Presentation Name/ 12pt - 393
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MCI.5 Clinical Communication
– There is a process to communicate patient
information between the care providers on an
ongoing basis or at key times in the care
process
– Information communicated includes
– the patient’s health status
– a summary of the care provided
– the patient’s progress
– (Examples: handovers from shift to shift or
from a physician to on call physician)
Client name/ Presentation Name/ 12pt - 394
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MCI.6 Patient Care Information
– Policy establishes those care providers
who have access to the patient’s clinical
record
– The record is available to those
providers
– The record is up to date to ensure
communication of the latest information
Client name/ Presentation Name/ 12pt - 395
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MCI.7 Medical Record Availability
– The patient’s record or a summary of patient
care information is transferred with the patient
to another service or unit in the hospital
– The summary contains:
– The reason for admission
– The significant findings
– Any diagnosis made
– Any procedures performed
– Any medications and other treatments
– The patient’s condition at transfer
Client name/ Presentation Name/ 12pt - 396
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MCI.8 Transfer Information
– The information needs of
– those who provide clinical services
– those who manage the organization
– individuals and agencies outside the
organization
are considered in the planning process
– The planning is appropriate to the
organization’s size and complexity
– (There is no written plan required)
Client name/ Presentation Name/ 12pt - 397
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MCI.9 Information Management
Planning
– There is a written policy for addressing the
privacy and confidentiality of information that
is based on and consistent with law and
regulation
– The policy is implemented
– Compliance with the policy is monitored
– The hospital has a policy that indicates
whether patients have access to their health
information and the process to gain access,
when permitted
Client name/ Presentation Name/ 12pt - 398
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MCI.10 Privacy and
Confidentiality
– There is a written policy addressing
information security, including data integrity
– The policy includes levels of security for each
category of data and information are identified
– Those who have need or job position that
permits access to each category of data and
information are identified
– The policy is implemented
– Compliance with the policy is monitored
Client name/ Presentation Name/ 12pt - 399
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MCI.11 Security and Integrity of Data
and Information
– The hospital has a policy on retaining
patient clinical records and other data
and information
– The retention process provides
expected confidentiality and security
– Records, data, and information are
destroyed appropriately
Client name/ Presentation Name/ 12pt - 400
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MCI.12 Retention of Records
– Standardized
– diagnosis codes are used & use monitored
– procedure codes are used & use monitored
– definitions are used
– symbols and a “do not use” listing are used
& use monitored
– abbreviations and a “do not use” listing are
used & use monitored
Client name/ Presentation Name/ 12pt - 401
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MCI.13 Standardized
Terminology
– Data and information dissemination
meet user needs
– Users receive data and information
– on a timely basis
– in a format that aids its intended use
– Staff have access to the data and
information needed to carry out their job
responsibilities
Client name/ Presentation Name/ 12pt - 402
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MCI.14 Disseminating Information
MCI.15 Staff Participation
– Managerial staff participates in
information technology decisions
Client name/ Presentation Name/ 12pt - 403
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– Clinical staff participates in
information technology decisions
MCI.16 Protection of Records
– Records and information are protected
from tampering and unauthorized
access or use
Client name/ Presentation Name/ 12pt - 404
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– Records and information are protected
from loss or destruction
– Decision makers and others are
provided education on the principles of
information management
– The education is appropriate to needs
and job responsibilities
– Clinical and managerial data and
information are integrated as needed to
support decision making
Client name/ Presentation Name/ 12pt - 405
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MCI.17 Principles of Information
Management
– There is a written policy or protocol that defines the
requirements for developing and maintaining PP
including at least:
– Review and approval of all PP by an authorized
person before issue
– Process and frequency of review and continued
approval of PP
– Controls for ensuring that only current, relevant
versions of PP are available wherever they are used
– Identification of changes in PP
– Maintenance of document identity and legibility
– All of the above components are implemented
Continue on next slide
Client name/ Presentation Name/ 12pt - 406
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MCI.18 Policy on Policies
– There is a written protocol that outlines how PP
that originated outside the organization will be
controlled, and it is implemented
– There is a written policy or protocol that defines
retention of obsolete PP for at least the time
required by law and regulation, while ensuring
that they will not be mistakenly used, and it is
implemented
– There is a written policy or protocol that outlines
how all PP in circulation will be identified and
tracked, and it is implemented
Client name/ Presentation Name/ 12pt - 407
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MCI.18 Policy on Policies
– A clinical record is initiated for every
patient (inpatients, outpatients,
emergency patients, etc) assessed or
treated by the organization
– Patient clinical records are maintained
through the use of an identifier unique
to the patient or some other effective
method
Client name/ Presentation Name/ 12pt - 408
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MCI.19 Clinical Records
– The specific content of patient clinical
records has been determined by the hospital
– Patient clinical records contain adequate
information to:
– Identify the patient
– Support the diagnosis
– Justify the care and treatment
– Document the course and results of
treatment
– See content of emergency record in
MCI.19.1.1 (next slide) Client name/ Presentation Name/ 12pt - 409
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MCI.19.1 Clinical Record Content
– The clinical records of emergency
patients include:
– Arrival time
– Conclusions at the termination of
treatment
– The patient’s condition at discharge
– Any follow-up care instructions
Client name/ Presentation Name/ 12pt - 410
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MCI.19.1.1 Emergency Clinical
Record
– Those authorized to make entries in the
patient clinical record are identified in
hospital policy
– The format and location of entries are
determined by hospital policy
– There is a process to ensure that only
authorized individuals make entries in
patient clinical records
Client name/ Presentation Name/ 12pt - 411
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MCI.19.2 Clinical Record Entries
– The author can be identified for each
patient clinical record entry
– The date of each patient clinical record
entry can be identified
– When required by the hospital, the time
of an entry can be identified
Client name/ Presentation Name/ 12pt - 412
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MCI.19.3 Author, Date and Time
in the Medical Record
– Patient clinical records are reviewed
regularly
– The review uses a representative
sample
– The review is conducted by medicine,
nursing, and others authorized to make
entries in patient records or manage
patient records
Client name/
Presentation
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MCI.19.4 Review of Clinical
Records
– The review focuses on the timeliness, legibility,
and completeness of the clinical record
– Record contents required by law or regulation
are included in the review process
– Records of active and discharged patients are
included in the review process
– The results of the review process are
incorporated into the hospital’s quality
oversight mechanism
Client name/ Presentation Name/ 12pt - 414
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MCI.19.4 Review of Clinical Records
MCI.20 Aggregate Data Support
Client name/ Presentation Name/ 12pt - 415
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– Aggregate data and information support
– patient care
– organization management
– the quality management program
– The hospital has a process to aggregate
data in response to identified user
needs
– The hospital provides needed data to
agencies outside the organization
Client name/ Presentation Name/ 12pt - 416
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MCI.20.1 Aggregation of Data
– Organization has a process to participate
in or use information from external data
bases
– Contributes data or information to
external data bases according to laws
or regulations
– Compares it’s performance using
external reference data bases
– Security and confidentiality are
maintained
Client name/ Presentation Name/ 12pt - 417
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MCI.20.2 Information Support
– Current scientific and other information
supports:
– Patient care
– Clinical education
– Research
– Management
– Information is provided in a time frame
that meets user expectation
Client name/ Presentation Name/ 12pt - 418
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MCI.21 Timely Information from
Current Sources
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Client name/ Presentation Name/ 12pt - 419