Transcript JCAHO UPDATE

JCAHO UPDATE
June 2005
The Bureau of Primary Health Care is
continuing to encourage Community
Health Centers to be JCAHO
accredited.
JCAHO’s new focus is on continuous
compliance.
Survey Changes for 2006
Unannounced surveys –at an
unscheduled date
Tracer Methodology: traces the care
experience that a patient has while at
the clinic
Tracer Methodology:
Patients are selected by type of visit or
use of cross services (i.e. medical and
behavioral health or dental) or as
related to topics such as medication
management or infection control.
Tracer Methodology:
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Surveyors observe and/or discuss with
staff:
Flow, management of risk points and
communications
Strengths in processes and
opportunities for improvement
Issues requiring additional attention
Baseline assessment
Tracer Methodology
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Surveyors look at the following at each
contact point:
Use of Data
Infection Control
Medication Management
Role of staff: care for patients, ability to
provide patient lists, etc.
Survey 2006
Shift from making high score to showing
evidence of maintaining safe, high
quality systems
If any Requirements for Improvement,
GCHD will submit an “Evidence of
Standards Compliance Report” within
45 days.
Most Challenging Standards for
Community Health Centers in 2004
A process for ensuring the competence
of all practitioners
Qualified individuals are granted clinical
privileges
Continued. . .
Contractual services provided safely
and effectively.
Leaders develop, implement, monitor
policies and procedures for care,
treatment and services
The organization conducts hazards
vulnerability analysis, etc.
Continued. . .
The organization monitors the
environment (annual evaluation of
plans for safety, security, fire safety,
utilities, hazardous materials, medical
equipment, emergency planning)
The organization establishes standards
for abbreviations, acronyms and
symbols as well as list of those not to
use.
Continued. . .
The medical record contains a summary
list of all significant diagnoses,
procedures, drug allergies and
medications.
The organization provides access to all
relevant patient medical records for use
in patient care, treatment and services.
Continued. . .
Pain is assessed and documented for
patients when warranted by the
patient’s condition.
The organization uses at least two
patient identifiers whenever taking blood
samples or administering medication
Documentation that the patient receives
education and training specific to their
needs and as appropriate to the care
and services.
Continued. . .
Quality control checks, as defined by
the organization, are conducted on each
lab procedure
Medications are properly and safely
stored
Continued. . .
Once the organization has prioritized its
goals for preventing health-care
acquired infections, strategies are
implemented to achieve those goals
(i.e. hand hygiene program).
More JCAHO Priorities for 2006
Use of current clinical guidelines – how
are they selected, updated, evaluated
Integrating and coordinating services –
i.e. communication with the pharmacy
on patient-significant data, coordinating
services in the clinic and in the
community
Improving safety performance – there is
a culture of safety/performance
improvement, there are resources for
staff and support, sentinel events are
managed
How we use patient satisfaction data to
improve services
Performance Improvement clinical
monitors: process and outcomes – the
PI plan is effective
Focus on National Patient
Safety Goals
Goal 1 Improve the accuracy of patient
identification
Goal 2 Improve the effectiveness of
communications among caregivers
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Use a “time out” to verify correct patient, correct
procedure, and correct body part during each
procedure
Goal 3 Improve the safety of using
medications.
Goal 7 Reduce the risk of health careassociated infections by adhering to
OSHA and CDC guidance.
Goal 8 Accurately and completely
reconcile medications across the
continuum of care.
Staying Ready for JCAHO
Use survey self-preparation tools
Identify changes in standards, priorities
Use analysis tools to identify
organization risk points
Train and cross-train staff