1. 1 Preparing for the JCIA Consultation Survey

2. 2 What will be presented  AUBMC Accreditation timeline  How JCIA standards are spelled out  How to get ready for the consultation survey  What you need to know  International Patient Safety Goals

3. 3 AUBMC Accreditation Timeline  JCIA Consultation Survey April 16 – 20 th 2007  Depending on the survey findings, and after a 6 months notification period, the actual JCIA survey can be conducted  MOPH Accreditation visit is due in May 2007

4. 4 How JCIA standards are spelled out Statement of the standard Intent Measurable Elements

5. 5 How to get ready for the consultation survey  AUBMC Mission Statement  AUBMC policies & procedures manual  Departmental policies & procedures manual  AUBMC Safety/Emergency Plans ● Safety plan ● Security plan ● Hazardous material & waste management plan ● Emergency response plan ● Fire safety plan ● Medication equipment plan ● Utility systems plan ● Infection control manual

6. 6 Access & Continuity of Patient Care:  Admission of patients (ACC-MUL-001)  Discharge of patients (ACC-MUL-002)  Transfer of patients (ACC-MUL-003)  Access to and sharing of Information about the patient’s care among all staff providing care to patients  Multidisciplinary Assessment and Reassessment of Patients (AOP-CLN-001)

7. 7 Patient and Family Rights Patient & family are informed of Patient Bill of Rights and participation in care process.   Patient handbook &posters around AUBMC

8. 8 Patient and Family Rights (cont’d) Confidentiality of information, security and privacy of patient.  Confidentiality, Security, Privacy & Release of Patient Information (MOI- MUL-002) Confidentiality Guidelines: Do not allow medical information on computer terminals to be visible to patients or other individuals not directly involved in the patients’ care. Exercise care when disposing of medical information. Do not place medical records or other medical information where they can be easily accessed or removed by unauthorized persons. Speak softly over the phone and try to avoid excessive use of the patient’s name. Do not discuss patient information with anyone in a social conversation. Exercise privacy when addressing patients. Do not discuss the reason for the patient’s visit in the waiting area or in the presence of others. Do not disclose results of tests to individuals not directly involved in the patients’ care. Do not reveal to unauthorized persons that a patient is, has been, or will be admitted to AUBMC.

9. 9 Patient and Family Rights (cont’d) Guidelines on Handling of Complaints at AUBMC 1. Try to resolve the complaint, if unresolved 2. Refer to the chairperson/department head 3. Nursing - related complaints - Director For Nursing Services 3. Safety - Safety Officer 4. Others - Patient's Relations Office Patient-care Complaints - Medical Center Director/AUBMC Risk Manager  Complaints & Complements Guidelines (GLD-ADM- 003)

10. 10 Patient and Family Rights (cont’d) Informed consent: Obtain informed consent for special procedures (list identified). Inform patient/family/guardian, in a language/format that is understood, about proposed treatment for care decisions. Document signature of patient/family/guardian on informed consent and specify name of guardian.  Patient Consent (PFR-MUL-001) Mission Statement:  AUBMC website & posted within AUBMC

11. 11 Quality Improvement and Patient Safety PDCA Model, indicators, all staff participation  PI Plan (QPS-MUL-002). Incident reporting, monitoring of errors.  Patient-Related Risk Management Plan (QPS- MUL-001) Prevention and Control of Infection  Hand Hygiene  The hospital wide PCI Manual is still under development by the Infection Control Program.

12. 12 Governance Leadership and Direction SubjectPage number 1.Department mission statement (optional) 2.Scope of services and hours of operation 3.Organization structure (represented in an organization chart and authority matrix) 4.Physical facilities (including physical layout and major equipment) 5.Safety and infection control procedures (in coordination with the Occupational Safety Officer and the Infection Control Program) 6.Internal performance improvement plan (selection and monitoring of indicators) 7.Departmental orientation program 8.Internal (operating) policies and procedures Departmental Policy and Procedure Manual, know the content

13. 13 Safety Plans  Fire Safety plan  No smoking policy within AUBMC  Smoking Policy  Preparing, testing and responding to disasters  Disaster plan  Hazardous materials inventory, handling, storage, use and the control and disposal of hazardous materials and waste. ● Handling spills in your workplace  hazardous materials  Regular staff education, training and documentation regarding safety plans  Training, testing & documentation of staff who operate & maintain medical & utility equipment

14. 14 Facility Management and Safety (manual under construction) Fire safety: RACE, PASS, 5555 Disaster plan: 9999, participation in drills Security: safegaurd children and vulnerable patients. Equipment management: training on new equipment, ensure functionality before patient use.

15. 15 Staff Qualifications & Education Job description: Each staff member’s responsibilities are defined.  HR Policy & Procedure Manual, Competency Management (SQE-HRD-001) Staff evaluation according to job description: Performance appraisal process done yearly.  Orientation Plan (SQE-HRD-004), Performance  Appraisal Policy (under development)

16. 16 Patient Medical Record  Records and information are protected from loss, destruction, tampering, and unauthorized access or use.  Health care providers have access to the information in a patient’s clinical record each time the patient is seen for a new or continuing care episode.  Medical Record Content and Documentation (MOI-MUL-003)

17. 17 2007 International Patient Safety Goals

18. 18 2007 International Patient Safety Goals Poster

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20. 20 Goal #1: Identify Patients Correctly Patient Identification Policy COP-MUL-009 Patient room number should not be used for patient identification.

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22. 22 Goal #2: Improve Effective Communication  Verbal orders have to be “read back” by the receiver to check for accuracy. Other communication methods used in AUBMC include:  Inter-shift report by nursing staff.  On-service/off-service notes in the Multidisciplinary Notes.  Hand over report between house staff.  Multidisciplinary morning rounds.

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24. 24 Goal #3: Improve the Safety of High-Alert Medications Nursing & Pharmacy Committee is working on the list of high alert medications.

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26. 26 Goal #4: Eliminate Wrong-Site, Wrong- Patient, Wrong-Procedure Surgery Pre-operative/Pre-procedure Verification Form:  First Verification is performed by the nurse before pre-medication.  Second Verification is performed by the nurse before the procedure.  Third Verification, “TIME OUT”, is performed just before starting the procedure.  “TIME OUT”: the nurse initiates the process, the surgeon and anesthetist verify the correct patient name, procedure and site.

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28. 28 Goal #5: Reduce the Risk of Health Care-Associated Infections All AUBMC Personnel shall use proper hand hygiene before: ● Patient contact ● Applying gloves before starting any patient related procedure such as: central- venous catheters (CVC), inserting urinary catheters, peripheral vascular catheters, or other invasive devices that do not require surgery ● Eating, drinking, preparing or handling food

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30. 30 Goal #6: Reduce the Risk of Patient Harm Resulting From Falls  Fall Risk Assessment Tool: initiated upon admission, then weekly and as condition evolves, for adults.  According to the findings, the patient is categorized as “at Risk” or “No Risk”.  If patient is at risk of fall, the patient is put on fall risk precaution.  In pediatric population, fall precaution is done daily.