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JCITRANSCRIPT
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The Numbers 97 full (initial/triennial) Hospital accreditation
surveys have been conducted using the 3rd
atio
nal
Edition manual. A total of 334 measurable elements scored
Not Met by at least one organization. No measureable element was scored more
than 8 times
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athan 8 times. Top 20 Not Met standards/MEs: Cited in at least 4 to 8 surveys each
The Top 20
AOP 1 2 SQE 10 (ME 3)
Not Met findings come from 9 chapters:
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AOP.1.2AOP.1.6 (ME 1)AOP.1.6 (ME 4)AOP.6.4 COP.3.8 ASC.3ASC.4
SQE.10 (ME 3)SQE.10 (ME 4) SQE.11 (ME 1)SQE.11 (ME 2)SQE.11 (ME 3) MMU.5.1MMU.6.1
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MMU.1GLD.1FMS.7.1
QPS.2.1 IPSG 3 IPSG 4
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The most Frequently Cited Standard The most frequently cited standard was
it d 8 ti
atio
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cited 8 times.
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AOP.1.6
AOP.1.6 Patients are screened for t iti l t t d f ti l d
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nutritional status and functional needs and are referred for further assessment and treatment when necessary.
ME#4 Qualified individuals develop criteria to identify patients who require
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acriteria to identify patients who require further functional assessment.
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Primary Issues Cited
No functional screening criteria developed
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developed No functional screening policy
developed If the hospital does not have physical
therapy department and related f i l th i it i
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aprofessionals, the screening criteria are developed by those without the appropriate credentials
Additional Standards to Discuss
All of the standards are importantat
iona
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We will discuss the following four standards to give you a better sense of why organizations miss critical standards.
In the appendix of this presentation we
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a In the appendix of this presentation, we list all of our top 20, and their primary problems.
Copyright, Joint Commission International, 2011. May not be used without permission. 115
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ASC.3
ASC.3 Policies and procedures guide the care of patients undergoing moderate
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care of patients undergoing moderate and deep sedation.
ME#3 There is a pre-sedation assessment, according to organization
li t l t i k d
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apolicy, to evaluate risk and appropriateness of the sedation for the patient.
Primary Issues Cited
No pre-sedation policy is developedP d ti li i t i li ith th
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Pre-sedation policy is not in line with the policy for pre-anesthesia assessment
Documented assessment does not meet policy requirements
Assessment does not really evaluate
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the risk of sedation Pre-sedation assessment is not
documented
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FMS.7.1
FMS.7.1 The plan includes prevention, l d t ti i
atio
nal
early detection, suppression, abatement, and safe exit from the facility in response to fires and non-fire emergencies.
ME#5 The program includes the safe exit
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aME#5 The program includes the safe exit from the facility when fire and non-fire emergencies occur.
Primary Issues Cited
Fire doors are locked or blockedEmergency exits are not marked or lighted
atio
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Emergency exits are not marked or lighted properly
Hall in patient units are clogged with equipment and supplies
Structural barriers of the building hamper exitI ti t id d h k l k th t
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a Inpatient corridor doors have key locks that could prevent occupant from exiting the room
Penetrations in smoke compartments
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International Patient Safety Goals
IPSG #3 Improve the Safety of High-Alert Medications
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Medications
ME #2 Concentrated Electrolytes are not present in patient care units unless clinically necessary and actions are t k t t i d t t
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ataken to prevent inadvertent administration in those areas where permitted by policy.
Primary Issues Cited
No policy is written at
iona
l
Concentrated solutions not secure when present and appropriately labeled
Unaware Magnesium Sulfate 50% is considered a concentrated electrolyteMany areas are identified as
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International Patient Safety Goals
IPSG #4 Ensure Correct-Site, Correct-P d C t P ti t S
atio
nal
Procedure, Correct-Patient Surgery
ME #4 The organization uses a check list and time-out procedure just before starting a surgical procedure
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astarting a surgical procedure.
Primary Issues Cited
No documented evidence of using a checklist
atio
nal
checklist Time-out is not documented Confusions about the difference
between the time-out and checklist Not used for all surgical procedures,
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e.g. dental & Cesarean section Resistance to using the protocol at all
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