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    16 views18 pages

    Jci Hand Book PDF

    Uploaded by

    Angeline Adrianne

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    EVO ep cc) Canad eon) ase rrr iene omnes reac pene eee Panes coer) JCIA 5 Sar Bi Apollo Hospitals Porras Whats JC? How is good for us? o1 Metcaton policy 8 Building a cutue of quay improvement @ Patient and family education 6 Inensively adresed Joissve % Cuaity ndators 8 Iniemational patient saay goals o Near iss ad sein! events 8 Barro cae % Infection conte 20 Patients dente 6 and washing tecniquos a Discharge planning 6 Isolation of patents wth communicable dsease 4 Discharge summary 6 Waste disposal 4 Color cang in isaster age 6 Handing soled nen 2% Routine tiage 6 Facity management and saley 2 Patient and fay rights o Formal cide cher hazmat pls Py Patient responsbiies 6 Merry soi 8 Assessment of patints « ‘Smoking poly 2» ‘Vulnerable patent 10 Fre satey 2» Pain management 10 Management of inomation and communication 2» Endo ile bse 10 Tineines x0 Restraint order " Emergency codes 3 Fgh isk pains and sences 1 Adu BLS 2 Timeout 2 ‘uric te marking 8 a a EE What is JCI? How is it good for us? GI stands for Joint Commission Intemational. tis a US based, not +f Profit acrectation body which sets and addresses standards forthe heath care provide’ level of performance in key functional areas, such 2s pationt rights, pationt treatment, and infection contro, How will it help us? GI standards woud lead us to improved patent care, salety and path of, ‘continuous quality improvement. JC standards would lead us to improved ‘edge. JCI accreditation is the gold standard for U.S. and European hospitals as it reflects provision ofthe highest levels of patent care and patient safely. The avcredtaton slandards are listed inthe fourth edition ‘of Joint Commission Intemational Accreditation Standards for Hospital ‘andar funcional didedinto 8 Patient centered chapers and 6 Organ- ‘ation Management cantered chapters. JCI Standards ‘The Patient Centered Standards are: 1. International Pationt Safety Goals (PSG) 2, Access to Care and Contiruiy of Care (ACC) 3, Patient and Family Fights (PFR) 4, Assessment of Patients (AP) 5. Care of Patients (COP) 6. Anesthesia and Surgical Care (ASC) 7. Medication Management and Use{ MMU) 6, Patients and Family Educaton (PFE) & ‘The Organization Management Standards are: 8, QualyInprevement and Patient Seely (QPS) 10, rovenon an Caio of Infections (PC) +1, Govemanes, Leadership and Dreion (GLO) 12, Facility Management and Safety (FMS) 18. Statf Qualification and Education (SQE) “4 Management of Communica and fomaton MCI) Building a Culture of Quality improvement... {ICI calls for setng standards for qualty of cfrical care and patient senvces, Curaim so do the ight thing, the ight way, the fist ime every time ur Approach (Quality indicators (indicator of perfomance) Data collected through indicators ‘Serve as evidence for inferences, & ( a) de ~ & 0 addresses the folowing issues very intensively 1. Daly assessment bya physician 2, Care of pationts undergoing moderate and deop sedation 3, Pain management 4, Patent satay issue 5, Department level plan for clinical services 6, Resuscttive technique training for stat 7. Managing documents such as poles and procedures '8.A process to help patients at times of sprtual and religious needs 8. End oflife care | a What we achieve: More efficent administrative processes 2g, Lesser wating time Lower costs better utiization of resources Better qualty of care Better patent satety-reduce mesicaton erors Improved outcomes of care of patients 29, Decreased motbisty and mortality rates ‘Standards: Total Number: 323 Standards ae set around the important functions; they are common to all healthcare organizations. Intent statement: Easy exolanaion ofthe standards Measurable Elements: Total number: 1134 Measurable elements are those requirements of standards which are reviewed and assigned a score during survey. ‘Survey: Assesses the hospitals compliance on JC! standards International Patient Safety Goals ‘The Purpose of Intemational Patient Safety Goals isto Promote spectic Improvements inpatient safety Goal 1: identity Patents Corstly Use two identiner’s other than room number Goal 2: Improve Effective Communication Use read back poly for verbal oder and laboratory test result obtained ‘onthe phone, Goal 3: improve the Safety o Hgh-aert medications Eg. Inj, Pottassium Chloride, In, Sodium Chioide more than 0.9%, Inj. Phosphate, Concentrated electrolytes are not to be stored inpatient ward but stored ‘only inthe IP Pharmacy. Goal 4: Ensure Cored Site, Correct Prooedure, Corect Patent Surgery Follow pre-surgcal site marking, pre-operative checklist and time out. = a Goal 5: Reduce the Fisk of Health Care Associatad infections Follow the hand hygiene guidelines. (Goal 6: Reduce the Rsk of Patient Harm Resulting fom fl ‘Salat st program ACCESS TO CARE AND CONTINUITY OF CARE Information about the hospital provided to the patients in patient (guide back. Removal of Barriers to care: Language: lis of interpreters avaiable in all using ston. Physical Wheelchair / stretchers are ready avalabe atthe entrance. Lits are availabe fr all foors. Religious Prayer Rooms are avaible. Spittal services are provided when asked for. Cuturaly diferent ypes ot fod are avaiable. Patient's needs to observe auspicious limes for any procedures are honored. Patient Identities Use at leat two patents identifiers (not tobe the patients room number) whenever taking blood samples, administering medicatons, or blood products. Nene Nare Unknown 123 UH HID tho &, a Discharge Planning Discharge planing is done atthe tine of admission so that a pation ‘needs even after discharge can be planned well ahead in time, This Improves the quality of patient care and decreases readmission due to lack of avalaity of vital equipment at home, afterdischarge Gonponnts of Discharge Summary 1. Thedscharge summary contains easan or adision, diagnoses and comoriaies 2. The dscharge summary contains sgiticant physical and cher figs. 3. The discharge summary contains dagnosic.and_ therapeutic [rooedures performed 4. The discharge sunmary contains significant medications, incu charge meicatons : cid 5. The discharge summary contains the pation contonstatus a the tie of ascharge 6, Tho cschage summary contains flowp nstucion. Color Coding in Disaster Triage: Red: Most urgent (patent needs o be seen immetkately) Yellow: Urgent Green :Non Urgent Black: Dead Routine Triage Hospital emergency oom ourenty uses a ir tage system, ‘The 3tier syst is based onthe folowing cessfcatons: Love 1 immediate) Level 2 (ery urgent Level (urgent) & Patient and Family Rights Patient's rights and responsbities have been defined and are actvely informed to the patients and families. Management ensures strict compl- ance with patient's ght and responstilties. Al vations ofthe poi are reviewed by the top management and actions are taken or prevent such incident inthe future, Following are the Rights of a Patient: ‘Fight to metical care ‘Infomation on identity othe sta taking care of them + A second opinion ‘Dignity + Conidentalty + Informed consent + Access to medical information Patient Responsibility Foloning are the responsibities of patos * To patcpae, ote best oftheir aby n making decisions about her treament and to comply withthe agreed pan of care, * To ask question of ther physician or oter care providers when they do tot undersand any infomation or insirucons. ‘To be considerate of ethers receiing and proviting care and also to cbsere facity poies and proodures, muting those regarding ‘smoking, nose and numberof vistors + Accept ancl responsibity fr heatbare received and ste bls prom a fo Assessment of Patient + All patents are assessed by a doctor and the history and physician ‘examination form filed within 24 hours of admission. +The nursing admission assessments also done within 24 hours + Nutritonal screening is dane for al patients and the diecian sees all cases. ‘Discharge planning i inated atthe time of admission +All paints are assessed for pain atthe time of admission and in every nursing si. Care of Patient Who isa vulnerable patient? + A child below 16 years of age + Adolescents «Frail > 65 years «Terminal i + Palenis wih intense or chronic pain + Women in labor + Women experiencing terminations in pregnancy + Patients wih emotional or psychiatre disorders + Palen suspected of crug and! ralctiol dependency + Vitis of abuse and neglect + Patients with infectious or communicable cseases + Patients receiving chemo or racation therapy + Palen whose immune systems are compromised + Patents on dialysis + Patients on retraint ‘Patients on ife support (Comatose) & For wlnerabe pati, prevention of false most important precauton toe taken The doctor identes a wnerble paint through a tek mark agains Safety Fr in"Request For Adnisslo’ Form. ‘What special care is given to a vulnerable patient? For children, there isa diferent Fistory and physical examination form, ‘Side rails are always put up onthe beds of vulnerable patints. ‘Safety First program is followed. A yelow ‘Saet Firs” tais paced atthe head fend of ther bed. ‘Plan of Care! form is added to the medical record Frequent assessments are done by doctor and nurses. All this is documented inthe pationts fle. Like all eter patens, an incident forms, filed in case of something untoward happening wth such a pater. Pain Management ‘Assessment and reassessment of pain is documented inthe inal and follow up notes, Patient and the family are educated on pain, Pain rating scale is used for assessment of pain, End of life Issues + Assessment and reassessment of dying patients on disease and secondary o treatment corded + Marage dying patents pan efectvely. + Pateis are educated about pairmanaged eect, *Risan extremely mporiant aspect of are, asses family fo psyhologe cal spirtual and bereavement suppor ané document th t least onc. + Cae givers respite needs are als taken care of, * yng patients are given contort and igi a fo oNR Never use the word DNR. "Do not Resusctate"(ONR) Orders are not legal. For brain dead patent fil the “End of Life Form” Restraint Order estat ede form has to be flee which i val or 24 hours oly Document the efor restates order) ro apirg esa person High Risk Patients and Services Extra caution shouldbe practiced in providing high risk services and for, high risk patients, according to laid policies + Polcies and Procedure for care of emergency patients * Policies and Procedure for care of ICU patients * Policies and Procedure for resuscitation series and folowed though- ‘out hospi! + Policies and Procedure fr blood and documented biod lated products + Polis for patients on lite support + Polis for care of alysis patents * Polis for use of retain and care of patints on restraint + Polis for care of vulnerable elder patients and children + Polis for car of patients undergoing moderate and deep sedation = a Anesthesia and Surgical Care + Pre anesthetic assessment and documentation mandatory + Care-planned and documented + isis, complications, options etc ae dscussed with patient and family members + Separate consent of anesthesia i obtained «Anesthesia used is documented «+ Physiclogial status during anesthesia is monitored and recorded + Post anesthesia status Is documented «Discharge or transfer from recovery is done using established ertria ‘Surgical Care + Patients surgical care is planned and recorded + isis, benefits, potential complication and options discussed with patient ‘and family and documerted + Surgery done is recorded: Pre-op and post-op diagnosis and operation notes are writen clearly + Care ater surgery is planned and documented Time out Prior tothe start of any surgical procedure, conduct final verification process such as a ‘Time Out fo confirm the correct patent, procedure and ste using active communication technique, a = Time Out MUST verity: 1. Comet patent 2. Comet side and ste (Marked) 3, Comec patient poston for procedure 4, Presence of implants and/or special equipment ‘Surgical site marking Surgical Ste Marking i done using oly arrows in all cases. vere we need to denote laterality, dg or level Medication Management and Use Medication Policy ‘We have & medication potcy in place to reduce medication eros. ‘Apotopsiate selection of medication for prescription is avalable-drug formulary ‘24 hours pharmacy senioes are avaible Emergency medicines are avalable and sored, +. Mediation ocders are to be wrtten clearly inthe drug char. 2, Start and discontinuation order of any drug has to be signed, dated and timed, 3, Any wrong enty has to be crossed out with a single line and signed ear 4. Etec of medication isto be documented inthe progres notes. 5, Mecications are administrated at tandaré times other than sat orders. 3} a 6, Self medication and medication from outside are not encouraged in the hospital 7. Never leave medicines unattended in the open. Keep them Locked, 8, Label ll open in use vials and pr-fled syringes. 9, All medication error tobe reported 10. All ADR need tobe reported in ADR form fr cinical aut 11. Al orders (including dt and nursing stands cancelled when patient under go surgery or is transfered out of ICU's, ll order including etary order, need tobe writen afresh inthe stuation, ‘Nurses will administer the medicines after cross checking: 1. Right patient 2. Right drug 23, Right dose 4. Right time 5, Right route 6. Right purpose 7 Right documentation & a Patient and Family Education Pationt and family should be educated about their disease process, propased plan of care and efet of treatment. Patient and family should be exlcated based on the individuals learning preferences, privieges, cutural values, reading and language skis. Educate patents on: 1 How to take medication safely 2. How to prevent fls 3. Food drug interactions 4, Nutiton This must be documented in the case recor, a ualty improvement and Patient Safety Organizational Quality Monitors: Clinical monitors: + Patent assossment ‘Lab safety and quality contro programs + Raciology qualty contol programs. + Surgical procedures + Use of anesthesia & sedation + Use of blood and biood products + Availabilty, content and use of patent records + Use of antiotc& other meication * Montring of medication errors & near misses “Infection contol, survellance and reporting ‘Managerial Monitors: + Procurement and supply + Patient satistacton ‘+ Repoding as per law and regulation * Biomedical waste management * Uilzation management ‘Needle sek injures + Stal satisfaction ‘Fisk management + Patent demographics & cinical agnosis + Financial management & Quality indicators ‘Af ofthe quality indicator used as cnical monitors include 1. Patient fas 2. Medicaton erors 3, Heetncare associated infections 4. Unplanned return to OT 5, Recovery room delays ‘Near Miss Events ‘near miss is defined as any process vation which didnot affect he ‘outcome but for which a recurence cartes a significant chance of a serious atverse outcome. E.g. a post operative patient slips in the bathroom but is immediately supported by the accompanying nurse preventing afl Sentinel Events ‘An unanticipated occurence inching death andlor major permanent loss of function & a Prevention and control of infections Infection control is everyone's responsibilty. Everyone can prevent infection anda of us nee to be equally conoemed wih infection conto inthe hospital ‘Wash hands belore and ater patient contact, belore eating, alter visting {olet and even ater touching inanimate objects ik fles, equipments etc ‘An infection control committee has been constituted, which serves as an advisory body. An infection convo! manual has been compiled and is Available with members of tho infection contol commitee& at all nursing stations. a The hospital has identied procedures associated wth sk of infection ‘and has strategies to rede infection risk 1. Hand Washing Hand washing is the single mast important factor fo Infection Conta Wash hands before! after patient contact and use of tales Follow "Standard precautions” in the hospital Hand Hygione Technique with Aleoho-Based Formulation © Duration ofthe entre Procedure 20-90 seconds SG Rae ee AN G a Hand Hygione Technique with Soap and Water bwration ot te ents procedure: 0-50 seconds BAD a-@. 6 < FR Ae 2. Isolation of Patients with Communicable Disease 3, Personal Protective Equipments (PPE) 4, Waste Disposal Segtagation of waste at source is very important and waste disposal should be done in corect color bags as per hospital poicy 5. Disposal of Sharps and Needles. ‘Sharp Conlaners 6. Biomedical Waste eon Gea oreo a a @ 7. Handling soled tinens ‘Any nen vsibly soiled with blood any body fui of a patient isto be ‘neated as soiled. A the laundry, tere i a special procedure for cleaning and dsinfecing of soled & infected linen, before sending it back tothe oars. 8. Scrub policy ‘Avoid wearing scrubs ouside restricted areas. Wear a long coat ove the scrubs if you have to go out of restricted ares. 9. Handling contaminated fles I blood & body fui is soiled onto a file, thal fle is fo be tected as contaminated and folowing instructions tobe done: + Place the fein plastic impervious yellow bag. ‘+ Fil an incident form, ‘The nurse shall send the fle to MAD where it wil be photocopied, attested and that copy of the fe wil be sent back to the for. 10. Kitten Food sanitation an handing 11. Mortuary area 12, Engineering control Negative pressure systems, bilogical hood in ab ete a Facility Management and Safety The management and safety ofthe hospital faites is an important part of quality improvement and patient safety. A safety committee has been constituted 1 act as an advisory body. The safety commit- tee conducts extensive safety rounds of the facies and offer suggestions for improvement. ‘A alely manual (also caled the RED BOOK) has been compiled by the safety commit, which gives information on staf response o hazardous situation Disaster plans nave also been formulated, and gives information on staf response to various “de" situations, pat of which i also included in the safely mara Mock cis for extemal interal disasters are conducted. ‘A policy for hazardous materials has been formulated, and must be scl folowed by ll sta members. ‘The basic responsibilities ofthe stat are: 1. Handling hazardous material spils mec sis, oman ane idx sil) 2. Fre satety 8. Smoking conto polcy Personal Protective Equipments (PPE) ‘You shoul knaw that each oor has one complete set of PPE for your use in case of need. Includes gloves, goggles, face mask, apron, qumiboots to use & replace 2) gS Formalin, dex and other Hazardous Material Spill Minor spills: 30ce 1. Place tissue paper over the spill 2. Plaoe inverted trash can over the sil 43 nform HAZMAT team to clean up (2200) 4.Fillup Incident Form Mercury Spi 1. All Mercury Spils are major spi. 2. They are caused by BP apparatus / thermometer break. 5. Place tssue paper over te sil 4, Place inverted rash can over the mercury. 5 Inform HAZMAT team to dean up (call 2200) 6. Filan incident Form, Material Satety Data Sheet (MSDS) - List the nature, safe use and precautions while handing hazardous Materials. a eo ‘SMOKING POLICY Hospital isa “NO SMOKING ZONE” Fre Safety Incase of ire, Call 4400 and Remember RACE P: Rescue ‘A: Alarm C: Contin te fire E: Extinguish or evacuate, “To use fre extinguisher Folows PASS Pull ion Squeeze Sweep [MANAGEMENT OF INFORMATION AND COMMUNICATION Safety Manual oe cere) perry eed een book * Nurses to be Conversant with Nurses Manual + Senior Medica Staff to be conversant wih Medica Staff Bylaws and Code of Ets, La) a Timelines Nursing Assessment Within 24 hours Restraint Form Valcy Within 24 hours Restraint monitoring Every 2 hours Vai of Blood Dialysis Consent Form: 30 Days IDTR Rounds | Within 48 hours Nutron Assessment Within 24 Hours Physiotherapy Assessment Within 24 hours Dos 1. Maintaining conidentalty of information pertaining 1o a. pationt, Confidentiality isa patent’ rght 2. All staf members are required to sign a “Contidentaty Agreement” Whereby they pledge to abide by the hosp paley on management o! information 3. Doctor to Doctor Communication: Read back and vey telephone orders and (imited) verbal orders. 4 Nurses and doctors to read back and very ctl test resus, 5, Take Informed consents. Don's 1. Do not ciscose information about the patient to anyone except the patent or a person approved by the patient 2. Donot discuss about patient inte it. fidentiiable information isbeing «iscussed, it can de a violation of confidentiality ‘8, Nurses shall not take verbal medication order fram doctors excopt in an emergency. 4. Doctor to doctor verbal order however allowed, with read back plc. a fo Dangerous abbreviation or case designation TNOT TOBE USED In meicl record. mae ee ee eatin | “om [ves | — Seen =| as eager ee ay ere cs eae ae a ise | aa | MCE or | a GREEERY ie eee, carrera “Mognesiom Sule | agmaston wen us wm |e, | & | mmmmyegemn Eee | sls rer ee =

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