2 nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future. JCAHO A Constant State of Readiness. How to Encourage Staff to Become Engaged and Involved While Focusing on Patient Safety. Kenneth H. Belcher. Boston University School of Medicine May 18, 2006. 11:00-11:30pm.
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Explain/ emphasize to staff and employees why JCAHO readiness is so important.
2nd Annual Ellison Pierce Symposium
Positioning your ORs for the Future
Demystify what it means to be
Actions to be taken to
become JCAHO Ready
Commitment must start at the top of the organization:
If there is not clear/obvious dedication at the top, readiness will be difficult to achieve and impossible to maintain.
Yes or No?
Yes or No?
Yes or No?
Yes or No?
DURING THESE TOURS
TO TEST FOR GENERAL STAFF KNOWLEDGE
WHAT IS THE MOST IMPORTANT MEASURE FOR REDUCING THE SPREAD OF GERMS IN THE HOSPITAL?
It means treating all patients’ blood, body fluids or specimens as if they were infected with a bloodborne pathogen – like Hepatitis B or C virus or HIV.
WHERE CAN YOU FIND YOUR HOSPITAL DISASTER PLAN?
All safety plans should be available.
WHO IS THE HOSPITAL SAFETY OFFICER?
Specific to your hospital.
WHAT WOULD HAPPEN IN THE EVENT OF AN ELECTRICAL POWER FAILURE?
All areas are equipped with emergency power to operate essential
services: all exit lights, certain hall lights, all RED receptacles.
MSDS are should be available in each department and all staff should know its exact location.
WHAT IS A HAZARD VULNERABILITY ANALYSIS (HVA)?
It is a formula used by the hospital to prioritize disaster planning. It uses the probability of an event occurring and the risk of harm to people and structures to identify the types of events we should be planning for.
Phase A - An administrative alert that something could happen to impact the hospital.
Phase B - An event that stresses the hospital but can be managed by the resources and staff available at the time.
Phase C - An event that disrupts hospital operations and/or requires support from city resources.
Phase D - An event that disrupts city operations and requires support from state and federal resources.
WHAT IS MY ROLE IN A DISASTER?
On-duty: During Phase B, C, or D report to your immediate supervisor. They will direct your next action.
Off-duty: If you become aware that a large scale disaster has occurred, make sure your family is safe and then call contact the hospital for instructions on how to proceed. If the phone lines are down, listen to the radio for announcements.
WHO IS AUTHORIZED TO SHUT OFF THE OXYGEN IN AN EMERGENCY?
The charge nurse.
Maintain compliance with National Patient Safety Goals (NPSG)
Likely same as JCAHO Steering
Clinical Leadership with NSPG Oversight
Boston Medical Center contracts with Press Ganey to conduct patient satisfaction surveys. Press Ganey surveys are conducted on inpatients and in some of the ambulatory settings. In addition, some services conduct their own patient satisfaction surveys. The results are shared at the monthly Leadership for Change meetings, as patient satisfaction is one of the performance indicators on Boston Medical Center's balanced scorecard.
WHAT IS THE APPROVED METHOD OF PERFORMANCE IMPROVEMENT AT BOSTON MEDICAL CENTER?
HOW ARE PATIENTS INFORMED ABOUT THEIR RIGHTS AND RESPONSIBILITIES?
All patients should be aware of their Rights and Responsibilities.
HOW ARE PATIENT COMPLAINTS HANDLED?
Hospitals should have a standard protocol in place to handle patient complaints.
HOW DO PATIENTS RECEIVE INFORMATION ABOUT HEALTH CARE PROXY/ ADVANCE DIRECTIVES?
Nursing staff, when completing the Multidisciplinary Admission History and Physical Assessment, will ask the patient if he/ she has a Proxy and document the patient's response. If the patient has executed a Proxy, but does not have a copy with him/ her, the nurse will document the content of the proxy, as stated by the patient. Patients and/ or their agent will be requested to bring a copy to be placed in the patient's medical record. Patients not having a Proxy will be offered an explanation. If the patient wishes to execute a Proxy during admission, Social Work is available to provide information and to assist with the completion of the Health Care Proxy.
In the outpatient areas, any patient requesting a Health Care Proxy should be referred to the Patient Advocate.
Testing for readiness/compliance.
Testing for Readiness
WHAT IS BOSTON MEDICAL CENTER'S MISSION?
Our mission is to provide consistently excellent and accessible health services to all in need of care, regardless of status or ability to pay.
An integral part of our mission is to continually improve upon service quality to all our patients. The physicians, employees and volunteers at BMC are committed to providing the highest level of quality, patient-centered care - exceptional care without exception.
WHAT IS BOSTON MEDICAL CENTER'S VISION?
Our vision is to provide the highest quality, comprehensive care to all of the people of Boston and its surrounding communities, and to be particularly mindful to the needs of vulnerable populations, in an ethically and financially responsible manner.
Do it all over again