John D. Crossley, RN, PhD

It is required that an academic medical center with a residency training program be accredited.
 The Accreditation Council on Graduate Medical Education (ACGME)
Institutional Requirements state: 'Institutions sponsoring participating
GME programs should be accredited by the JCAHO, if such institutions are eligible.
 If an institution is eligible for JCAHO accreditation and chooses not to undergo such accreditation, then the institution should be reviewed by and meet the standards of another recognized body with reasonably equivalent standards. If the institution is not accredited, it must provide a satisfactory explanation of why accreditation has not been either granted or sought.'
 ACGME notes that certain specialty training programs , like general surgery should be conducted in institutions accredited by JCAHO.
http://www.aha.org/aha/key_issues/patient_safety/accreditation/

A hospital or health system that does not have deemed status is able to participate in Federal health care programs such as Medicare – which funds GME- but:
If a hospital or health system chooses not to be accredited by either the JCAHO or the American Osteopathic
Association, the organization will be subject to periodic surveys by personnel of the respective state agency that licenses hospitals and other health care facilities (or its equivalent). The results of such surveys will serve to determine whether a hospital or health care system is eligible to participate in such Federal programs as Medicare.
http://www.aha.org/aha/key_issues/patient_safety/accreditation /

 Scheduled months in advance
 Primarily a retrospective review
 Small teams of part-time surveyors with limited training
 Unstructured care area visits
 Focus on prior survey reports
 Tailored primarily to national highvolume diagnoses

 No scheduled surveys
 Minimal retrospective review
 Larger teams of full-time surveyors with extensive training
 Tracer methodology
 Global priority focus areas
 Tailored to current inpatient census

 Structured, based on physical patient care areas
 Uniform across all organizations surveyed
 Unit/clinic visits tightly scheduled and controlled
 Primarily managerial staff participation in survey
 Main focus on policies and procedures

 Process-driven, directed by priority focus areas
 Customized to the individual health care organization
 Surveys follow provision of services across physical and programmatic boundaries
 Multi-level staff participation
 Main focus on actual care delivery

 Each standard relates to one or more priority focus area
 “Processes, systems, or structures in a health care organization that significantly impact the quality and
safety of care.” 2005 CAMH
 Serve to integrate chapter elements of the accreditation standards

Goal: Improve the accuracy of patient identification.
 Use at least two patient identifiers
(neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.

Goal: Improve the effectiveness of communication among caregivers.
 For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result " readback" the complete order or test result.
 Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.
 Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values

1.
Q.D.
2.
Q.O.D.
3.
U.
4.
IU
Write “daily”
Write “every other day”
Write unit
Write international unit

5.
Trailing zero (1.0 mg)
Never write a zero by itself after a decimal point
(1 mg)
6 .
Lack of leading zero (.1mg)
Always use a zero before a decimal point (0.1 mg)

7.
MS
8.
MS04
Write morphine sulfate or magnesium sulfate
Write morphine sulfate
9.
MgSO4 Write magnesium sulfate
10.
Ug Write mcg or micrograms
11.
Cc
12.
T.I.W.
Write ml or milliliter
Write 3 times weekly or three times weekly

Goal: Improve the safety of using medications.
 Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.
 Standardize and limit the number of drug concentrations available in the organization.
 Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.

Goal: Improve the safety of using infusion pumps.
 Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.

Goal: Reduce the risk of health careassociated infections.
 Comply with current Centers for Disease
Control and Prevention (CDC) hand hygiene guidelines.
 Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

 Contact with a patient’s intact skin
 Contact with environmental surfaces in the immediately vicinity of patients
 After glove removal

Goal: Accurately and completely reconcile medications across the continuum of care .
 During 2005, for full implementation by January 2006, develop a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient . This process includes a comparison of the medications the organization provides to those on the list.
 A complete list of the patient's medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

Goal: Reduce the risk of patient harm resulting from falls.
 Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to address any identified risks.

 Assessment and Care/Services
 Communication*
 Credentialed Practitioners
 Appropriate Life Support certifications
 Valid permit or Texas license
 Equipment Use
 Infection Control
 Information Management*
 Medication Management*

 Organizational Structure
 Orientation and Training
 Patient Safety
 Physical Environment
 Quality Improvement Expertise and
Activity*
 Rights and Ethics
 Staffing
* Particular focus

 Converts pre-survey data into:
 information to focus survey activities,
 increase consistency in the survey process,
 customize the accreditation process.

Scott and White prepared for Tracer
Methodology by:
 Inviting a Consultant team from Joint
Commission Resources: physician, nurse, and administrator
 Nominating 48 S&W staff to be trained
 Offering a day of didactic presentation & one half day of a tracer demonstration

 Food in all patient care areas
 Fragmented medical records with documents missing
 No hand washing
 Staff unaware of unit/clinic results on performance measures
 Unsecured medications

Performance Measures
Percent of Heart Attack Patients Given ACE Inhibitor for LVSD
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
75%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 71%
 SCOTT & WHITE MEMORIAL
HOSPITAL 81%

Performance Measures
Percent of Heart Attack Patients Given Adult Smoking
Cessation Advice/Counseling
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
75%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 73%
 SCOTT & WHITE MEMORIAL
HOSPITAL 91%

Performance Measures
Percent of Heart Attack Patients Given Aspirin at
Arrival
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
91%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 90%
 SCOTT & WHITE MEMORIAL
HOSPITAL 93%

Performance Measures
Percent of Heart Attack Patients Given Aspirin at
Discharge
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
86%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 85%
 SCOTT & WHITE MEMORIAL
HOSPITAL 96%

Performance Measures
Percent of Heart Attack Patients Given Beta Blocker at
Arrival
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
84%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 81%
 SCOTT & WHITE MEMORIAL
HOSPITAL 97%

Performance Measures
Percent of Heart Attack Patients Given PTCA Received
Within 90 Minutes Of Arrival
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
37%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 38%
 SCOTT & WHITE MEMORIAL
HOSPITAL No data

Performance Measures
Percent of Heart Attack Patients Given Thrombolytic
Agent Received Within 30 Minutes Of Arrival
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
37%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 28%
 SCOTT & WHITE MEMORIAL
HOSPITAL No data

Performance Measures
Percent of Heart Failure Patients Given ACE Inhibitor for LVSD
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
74%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 73%
 SCOTT & WHITE MEMORIAL
HOSPITAL 76%

Performance Measures
Percent of Heart Failure Patients Given Adult
Smoking Cessation Advice/Counseling
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
65%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 62%
 SCOTT & WHITE MEMORIAL
HOSPITAL 44%

Performance Measures
Percent of Heart Failure Patients Given Assessment of
Left Ventricular Function
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
78%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 72%
 SCOTT & WHITE MEMORIAL
HOSPITAL 92%

Performance Measures
Percent of Heart Failure Patients Given Discharge
Instructions
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
45%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 42%
 SCOTT & WHITE MEMORIAL
HOSPITAL 17%

Performance Measures
Percent of Pneumonia Patients Given Adult Smoking
Cessation Advice/Counseling
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
61%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 58%
 SCOTT & WHITE MEMORIAL
HOSPITAL 26%

Performance Measures
Percent of Pneumonia Patients Given Blood Cultures
Performed Before First Antibiotic Received
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
82%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 79%
 SCOTT & WHITE MEMORIAL
HOSPITAL 83%

Performance Measures
Percent of Pneumonia Patients Given Initial Antibiotic
Timing
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
72%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 70%
 SCOTT & WHITE MEMORIAL
HOSPITAL 55%

Performance Measures
Percent of Pneumonia Patients Given Oxygenation
Assessment
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
98%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 97%
 SCOTT & WHITE MEMORIAL
HOSPITAL 98%

Performance Measures
Percent of Pneumonia Patients Given Pneumococcal
Vaccination
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE UNITED STATES
43%
 AVERAGE FOR ALL REPORTING
HOSPITALS IN THE STATE OF TEXAS -
EASTERN & SOUTHERN 38%
 SCOTT & WHITE MEMORIAL
HOSPITAL 27%

 Accredited
 Provisional Accreditation
 Conditional Accreditation
 Preliminary Denial of Accreditation
 Denial of Accreditation
 Immediate Threat to Life

 Scott and White would have failed

 “A” List
 Must do: no question, no debate
 “B” List
 Must do: can be modified to accommodate S&W practices
 “C” List
 Should do: JCAHO standards which, if not met, will result in demerits but not loss of accreditation

 Remove all food in patient care work areas
 Follow CDC guidelines for hand washing
 Use of only approved abbreviations
 Have qualified staff and equipment for patient population served
 Practice time outs prior to surgery and other invasive procedures to verify right patient, right procedure, right site

 Please proceed to the post test
 Download the post test
 Complete the post test
 Return the post test to Dr. S.K. Oliver
407i TAMUII

Indications for handwashing include all of the following except:
A. Contact with a patient’s intact skin
B. Contact with environmental surfaces in the immediately vicinity of patients
C. After glove removal
D. Before entering a patient room

Scott and White performed least well in which of the following performance areas:
A.
Percent of Heart Attack Patients Given Aspirin at Arrival
B.
Percent of Heart Attack Patients Given Beta Blocker at
Arrival
C.
Percent of Heart Failure Patients Given Discharge
Instructions
D.
Percent of Pneumonia Patients Given Blood Cultures
Performed Before First Antibiotic Received

 Please rewrite this these orders:
1.
6.U Regular Insulin Now
_____________________________
1.
Pot chloride 10 meq 1 po QID #90
______________________________