JCAHO UPDATE

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JCAHO UPDATE

• June 2005

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• The Bureau of Primary Health Care is continuing
  to encourage Community Health Centers to be JCAHO
  accredited.
• JCAHOs new focus is on continuous compliance.

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Survey Changes for 2006

• Unannounced surveys at an unscheduled date
• Tracer Methodology traces the care experience
  that a patient has while at the clinic

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Tracer Methodology

• Patients are selected by type of visit or use of
  cross services (i.e. medical and behavioral
  health or dental) or as related to topics such as
  medication management or infection control.

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Tracer Methodology

• Surveyors observe and/or discuss with staff
• Flow, management of risk points and
  communications
• Strengths in processes and opportunities for
  improvement
• Issues requiring additional attention
• Baseline assessment

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Tracer Methodology

• Surveyors look at the following at each contact
  point
• Use of Data
• Infection Control
• Medication Management
• Role of staff care for patients, ability to
  provide patient lists, etc.

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Survey 2006

• Shift from making high score to showing evidence
  of maintaining safe, high quality systems
• If any Requirements for Improvement, GCHD will
  submit an Evidence of Standards Compliance
  Report within 45 days.

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Most Challenging Standards for Community Health
Centers in 2004

• A process for ensuring the competence of all
  practitioners
• Qualified individuals are granted clinical
  privileges

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Continued. . .

• Contractual services provided safely and
  effectively.
• Leaders develop, implement, monitor policies and
  procedures for care, treatment and services
• The organization conducts hazards vulnerability
  analysis, etc.

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Continued. . .

• The organization monitors the environment (annual
  evaluation of plans for safety, security, fire
  safety, utilities, hazardous materials, medical
  equipment, emergency planning)
• The organization establishes standards for
  abbreviations, acronyms and symbols as well as
  list of those not to use.

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Continued. . .

• The medical record contains a summary list of all
  significant diagnoses, procedures, drug allergies
  and medications.
• The organization provides access to all relevant
  patient medical records for use in patient care,
  treatment and services.

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Continued. . .

• Pain is assessed and documented for patients when
  warranted by the patients condition.
• The organization uses at least two patient
  identifiers whenever taking blood samples or
  administering medication
• Documentation that the patient receives education
  and training specific to their needs and as
  appropriate to the care and services.

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Continued. . .

• Quality control checks, as defined by the
  organization, are conducted on each lab procedure
• Medications are properly and safely stored

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Continued. . .

• Once the organization has prioritized its goals
  for preventing health-care acquired infections,
  strategies are implemented to achieve those goals
  (i.e. hand hygiene program).

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More JCAHO Priorities for 2006

• Use of current clinical guidelines how are they
  selected, updated, evaluated
• Integrating and coordinating services i.e.
  communication with the pharmacy on
  patient-significant data, coordinating services
  in the clinic and in the community

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• Improving safety performance there is a culture
  of safety/performance improvement, there are
  resources for staff and support, sentinel events
  are managed
• How we use patient satisfaction data to improve
  services
• Performance Improvement clinical monitors
  process and outcomes the PI plan is effective

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Focus on National Patient Safety Goals

• Goal 1 Improve the accuracy of patient
  identification
• Goal 2 Improve the effectiveness of
  communications among caregivers
• Use a time out to verify correct patient,
  correct procedure, and correct body part during
  each procedure

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• Goal 3 Improve the safety of using medications.
• Goal 7 Reduce the risk of health care-associated
  infections by adhering to OSHA and CDC guidance.
• Goal 8 Accurately and completely reconcile
  medications across the continuum of care.

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Staying Ready for JCAHO

• Use survey self-preparation tools
• Identify changes in standards, priorities
• Use analysis tools to identify organization risk
  points
• Train and cross-train staff