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JCAHO Jeopardy. Kelly D. Young, MD, MS Harbor-UCLA Medical Center. JCAHO BASICS. PATIENT SAFETY. WORK- PLACE. DOCUMEN-TATION. POT-POURRI. $100. $100. $100. $100. $100. $200. $200. $200. $200. $200. $300. $300. $300. $300. $300. $400. $400. $400. $400. $400. $500. $500.

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JCAHO Jeopardy

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JCAHO Jeopardy

Kelly D. Young, MD, MS

Harbor-UCLA Medical Center































JCAHO Basics $100

What does JCAHO stand for?


Hint: It’s not “Julie Comes And Hangs Out”

Return to Jeopardy

Answer JCAHO Basics $100

Joint Commission on Accreditation of Healthcare Organizations

AKA “Yes, we can close your hospital and make you seek new residencies”

JCAHO Basics $200

  • During the JCAHO survey, the surveyors will talk primarily to:

  • The hospital administrators

  • The doctors and nurses

  • The patients

  • The LA Times


Return to Jeopardy

Answer JCAHO Basics $200


That’s why you’re playing this game, right?

JCAHO Basics $300

What is “tracer methodology”?


Return to Jeopardy

Answer JCAHO Basics $300

Surveyors analyze a hospital’s systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.

JCAHO Basics $400

What is HIPAA? Name one way protected health information is kept private in your department.



Return to Jeopardy

Answer JCAHO Basics $400

  • HIPAA: Health Insurance Portability and Accountability Act

  • States that PHI may only be used for purposes of treatment, payment, healthcare operations

  • Shredder or blue HIPAA trashcan for HIPAA sensitive documents

  • Codes for patient chief complaints

  • DON’T use “5150” or “OD” on the board

  • Don’t discuss patients in hallways or elevators

  • Keep curtains closed and don’t let patients

    stare at the board

JCAHO Basics $500

What is ORYX?

Bonus $100: name one core measure of ORYX


Answer JCAHO Basics $500

  • ORYX is an initiative that requires hospitals to collect and submit electronically data each quarter

  • Heart failure

    • Discharge instructions: activity, diet, follow-up, medications, symptoms worsening, weight monitoring

    • LV function assessment

    • ACE inhibitor for LV systolic dysfunction

    • Adult smoking cessation advice / counseling

More next slide

Return to Jeopardy

Answer continued

  • Pneumonia

    • Adult initial antibiotic within 4 hrs

    • Median time to first antibiotic dose (goal 240 minutes)

    • Adult blood culture before first antibiotic IF blood culture performed at all

    • Pneumococcal vaccination

    • Adult smoking cessation advice/counseling

    • Adult oxygenation assessment

  • Pregnancy and related conditions

    • VBAC, inpatient neonatal mortality, 3rd & 4th lacs

Patient Safety $100

Name one of the 2009 National Patient Safety Goals


Return to Jeopardy

Answer Patient Safety $100

  • Improve accuracy of patient identification

  • Improve effectiveness of communication among caregivers

  • Improve safety of using medications

  • Reduce risk of health-care associated infections

  • Accurately & completely reconcile medications across continuum of care

    • Medicine reconciliation form

  • Identify safety risks inherent to population (e.g. suicide

Med Reconciliation Form

Check whether to stop old meds

Patient gets yellow copy

List new long-term meds here and write in layperson lingo

Fill out your name, number, date, time, etc.

Patient Safety $200

Name one way you reduce the risk of health-care associated infections in your department


Return to Jeopardy

Answer Patient Safety $200

  • Handwashing with soap and water before AND after each patient contact

    • Even if you used gloves

    • Wash vigorously for 15 seconds

  • Alcohol-based hand rubs may be used if there is no visible soiling and C. diff is not suspected

  • Use of artificial or long fingernails is prohibited


Patient Safety $300

How do you improve the accuracy of patient identification in your department?


Return to Jeopardy

Answer Patient safety $300

  • I use TWO (2) (dos) identifiers when providing treatment, administering medications, collecting specimens, discharging the patient

  • Patient’s name

  • Patient’s MRUN

  • NOT patient’s room number or chief complaint (e.g. the lac in room 6)

Patient Safety $400

How are you improving the effectiveness of communication between caregivers?


Return to Jeopardy

Answer Patient Safety $400

  • Telephone orders are read back

  • Verbal orders are repeated back

  • Critical lab values and other test results are read back

  • We use standardized abbreviations and avoid certain unapproved dangerous abbreviations

  • Preliminary radiology reads in

    Notes feature of Synapse –

    Overread by radiologist and we

    are notified of any disagreements

Patient Safety $500

Name 3 of the unapproved abbreviations


U or u (unit)

IU (international unit)

Ug (microgram)

1.0 (no terminal zeros)

.5 (always use a leading zero – “always lead, never follow”))

X3d (for 3 days or for 3 doses)

TIW (three times weekly)

qD or qoD (every day, daily, or every other day)

MS, MSO4, MgSO4 (morphine sulfate or magnesium sulfate)

Return to Jeopardy

Answer Patient Safety $500

Workplace $100

Where are the fire extinguishers in the PED?


Where’s the oxygen shutoff valves in case of a fire?


Return to Jeopardy

Answer Workplace $100

  • Next to the nurses’ lounge as you go back toward the IR rooms

  • Opposite the white board with patient names

  • Oxygen shutoff valves

    • Between rooms 3 & 4 for Rooms 3-8

    • In hallway on the way to AED waiting room for back I-R rooms

Workplace $200

What color “code” would you call if you had a violent patient? Who would come?


Return to Jeopardy

Answer Workplace $200

  • Code Green

  • Crisis Response Team responds

  • Does NOT include police officer

  • ED staff are still responsible for the patient, and should assist in restraint if necessary

Workplace $300

What do the RACE and PASS mnemonics stand for when there is a fire?


Remove patients and others


Contain the fire (close doors)

Extinguish the fire when it is safe to do so

Pull the pin

Aim the nozzle at the base of the fire

Squeeze the handle

Sweep the nozzle from side to side

Return to Jeopardy

Answer Workplace $300

Workplace $400

What should you do in the event of a hazardous material spill?*


* Material more hazardous than cafeteria food, but less hazardous than anthrax

Return to Jeopardy

Answer Workplace $400

  • Rinse exposure with water

  • Post warning signs

  • Cordon off area

  • Consult Material Safety Data Sheet (MSDS) or call Hazardous Material Safety Office

Workplace $500

What are code pink, code white, code orange, code gray, and code triage?

($100 per correct answer)


Return to Jeopardy

Answer Workplace $500

  • Code pink: infant / child abduction

    • The number afterwards refers to the age of the child, e.g. Code pink 3

  • Code white: pediatric code blue

  • Code gray: bomb threat

  • Code orange: hazardous material or radiation spill / exposure

  • Code triage: disaster

Documentation $100

How do you document in your procedure note that you confirmed the correct identity of the patient, and the correct site of the procedure?


Return to Jeopardy

Answer Documentation $100

Document that a “time out” was done (check box on procedure note area of 253 form)

Documentation $200

How would you write the order for 100 mg of Motrin to be given to a 10 kg child PO?*


* Answer is NOT “with a pen”

Return to Jeopardy

Answer Documentation $200

Motrin 100 mg = 10 mg/kg PO now

Must put mg/kg

(Date and time order, of course)

Documentation $300

What’s wrong with this order?

Motrin 600 mg PO q 6-8 hours prn pain (standard adult dose)


Return to Jeopardy

Answer Documentation $300

No range orders allowed

(No range in doses, no range in time intervals)

Documentation $400

Which is acceptable?


Return to Jeopardy

Answer Documentation $400

  • C

  • Signature

  • Last name legibly spelled out

  • Degree (MD, RN, PNP, etc.)

  • Identification number

Documentation $500

What’s the “fifth vital sign” that we document on ALL patients, and where do we document it?


Return to Jeopardy

Answer Documentation $500

  • PAIN score

  • PAIN score

  • PAIN score (am I getting through?)

  • Pre-printed pain scales on 1st AND 3rd page of 253s


Pain med w/in 30min

Reassess w/in 30min of IV/IM pain med, w/in 60min of PO

Pain score < 4 at d/c or pain med for home

Potpourri $100

True of False:

A minor sibling may translate for the parent if the minor is 13 years old or older, clearly fluent in both languages, and the parent and minor consent to using the minor as an interpreter



“El bebe tiene mucho fiebre, hasta ciento siete, y no come nada, nunca, en todo su vida, (esos Cheetos son la primera comida de todo su vida), y tiene fiebre por dos o tres meses, y le duele todo su cuerpo, y tiene ronchas y grippe y tos y nausea y diarrea…”

Sibling Interpreter

“Tiene fiebre?”


Return to Jeopardy

Answer Potpourri $100


Potpourri $200

Does Harbor have a mission?


It’s not “To get our residents more sleep and more money.”

Return to Jeopardy

Answer Potpourri $200

Mission: to provide high quality, cost-effective, patient-centered care through leadership in medical practice, education and research.

Potpourri $300

What quality performance data are collected in your area, and how are you involved?


Return to Jeopardy

Answer Potpourri $300

Residents perform peer review of AED and PED charts for pain assessment and management. The data are collated and shared on a quarterly basis, and individual residents also receive a report of how they performed. Also, chart review 8am in the PED.

Potpourri $400

Dr. X is starting his shift in the PED. He walks down the hall, Starbucks in hand, and waves “hi” to the nurses and clerk. He rounds the corner, going through the propped open door to stand in front of the board. He notes that there are 2 patients with the same initials on the board. He dumps his empty coffee cup in the trash, sets down his trusty Harriet Lane Handbook on the counter, and picks up a chart. Where’s the JCAHO violation?


Return to Jeopardy

Answer Potpourri $400

Only special fire doors may remain open. Doors may not be propped open (including the 2 doors on either side of the PED board).

Potpourri $500

  • A two-parter:

  • How do you know a piece of equipment (e.g. defibrillator, ultrasound) is okay to use?

  • What does the pink tubing around the IV pole on the code cart mean?


Return to Jeopardy

Answer Potpourri $500

  • Check on the equipment for a dated sticker that it has been serviced by mechanical.

  • Pink signifies a “combination cart” which has supplies for both pediatric and adult codes.

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