JCAHO Jeopardy
Kelly D. Young, MD, MS
Harbor-UCLA Medical Center
JCAHO
BASICS
PATIENT
SAFETY
$100
$100
$200
WORKPLACE
DOCUMENTATION
POTPOURRI
$100
$100
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$200
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$300
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JCAHO Basics $100
What does JCAHO
stand for?
Answer
Hint: It’s not “Julie Comes And Hangs Out”
Answer JCAHO Basics $100
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Joint Commission on
Accreditation of Healthcare
Organizations
AKA “Yes, we can close your hospital and make
you seek new residencies”
JCAHO Basics $200
During the JCAHO survey, the
surveyors will talk primarily to:
A) The hospital administrators
B) The doctors and nurses
C) The patients
D) The LA Times
Answer
Answer JCAHO Basics $200
B) YOU!
That’s why you’re
playing this game,
right?
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JCAHO Basics $300
What is “tracer
methodology”?
Answer
Answer JCAHO Basics $300
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Surveyors analyze a hospital’s
systems by following individual
patients through their
hospitalization, evaluating
multiple care units,
departments, and services
rendered to the patient.
JCAHO Basics $400
What is HIPAA? Name
one way protected health
information is kept
Answer
private in your
department.
NOT HIPPO!
Answer JCAHO Basics $400
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HIPAA: Health Insurance Portability and
Accountability Act
States that PHI may only be used for purposes of
treatment, payment, healthcare operations
Shredder or blue HIPAA trashcan for HIPAA
sensitive documents
Codes for patient chief complaints
DON’T use “5150” or “OD” on the board
Don’t discuss patients in hallways or elevators
Keep curtains closed and don’t let patients
stare at the board
JCAHO Basics $500
What is ORYX?
Bonus $100: name one
core measure of ORYX
Answer
Answer JCAHO Basics $500
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ORYX is an initiative that requires hospitals
to collect and submit electronically data
each quarter
Heart failure
– Discharge instructions: activity, diet, follow-up,
medications, symptoms worsening, weight
monitoring
– LV function assessment
– ACE inhibitor for LV systolic dysfunction
– Adult smoking cessation advice / counseling
More next slide
Answer continued
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Pneumonia
– Adult initial antibiotic within 4 hrs
– Median time to first antibiotic dose (goal 240
minutes)
– Adult blood culture before first antibiotic IF blood
culture performed at all
– Pneumococcal vaccination
– Adult smoking cessation advice/counseling
– Adult oxygenation assessment
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Pregnancy and related conditions
– VBAC, inpatient neonatal mortality, 3rd & 4th lacs
Patient Safety $100
Name one of the 2009
National Patient Safety
Goals
Answer
Answer Patient Safety $100
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Improve accuracy of patient identification
Improve effectiveness of communication among
caregivers
Improve safety of using medications
Reduce risk of health-care associated infections
Accurately & completely reconcile medications
across continuum of care
– Medicine reconciliation form
Identify safety risks inherent to population (e.g.
suicide
Med Reconciliation Form
Check whether to
stop old meds
Patient gets yellow copy
List new long-term
meds here and write in
layperson lingo
Fill out your name,
number, date, time, etc.
Patient Safety $200
Name one way you reduce
the risk of health-care
associated infections in your
department
Answer
Answer Patient Safety $200
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Handwashing with soap and water before
AND after each patient contact
– Even if you used gloves
– Wash vigorously for 15 seconds
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Alcohol-based hand rubs may be used if
there is no visible soiling and C. diff is not
suspected
Use of artificial or long fingernails is
prohibited
LATHER UP!
Patient Safety $300
How do you improve the
accuracy of patient
identification in your
department?
Answer
Answer Patient safety $300
• I use TWO (2) (dos) identifiers when
providing treatment, administering
medications, collecting specimens,
discharging the patient
• Patient’s name
• Patient’s MRUN
• NOT patient’s room number or chief
complaint (e.g. the lac in room 6)
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Patient Safety $400
How are you improving
the effectiveness of
communication between
caregivers?
Answer
Answer Patient Safety $400
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Telephone orders are read back
Verbal orders are repeated back
Critical lab values and other test results are read
back
We use standardized abbreviations and avoid
certain unapproved dangerous abbreviations
Preliminary radiology reads in
Notes feature of Synapse –
Overread by radiologist and we
are notified of any disagreements
Patient Safety $500
Name 3 of the unapproved
abbreviations
Answer
Answer Patient Safety $500
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U or u (unit)
IU (international
unit)
Ug (microgram)
1.0 (no terminal
zeros)
.5 (always use a
leading zero –
“always lead, never
follow”))
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X3d (for 3 days or
for 3 doses)
TIW (three times
weekly)
qD or qoD (every
day, daily, or every
other day)
MS, MSO4, MgSO4
(morphine sulfate or
magnesium sulfate)
Workplace $100
Where are the fire
extinguishers in the PED?
BONUS:
Where’s the oxygen
shutoff valves in case
of a fire?
Answer
Answer Workplace $100
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1) Next to the nurses’ lounge as you go
back toward the IR rooms
2) Opposite the white board with patient
names
3) Oxygen shutoff valves
Between rooms 3 & 4 for Rooms 3-8
In hallway on the way to AED waiting
room for back I-R rooms
Workplace $200
What color “code” would
you call if you had a violent
patient? Who would come?
Answer
Answer Workplace $200
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Code Green
Crisis Response Team
responds
Does NOT include police
officer
ED staff are still responsible
for the patient, and should
assist in restraint if necessary
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Workplace $300
What do the RACE and PASS
mnemonics stand for when
there is a fire?
Answer
Answer Workplace $300
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Remove patients
and others
Alarm
Contain the fire
(close doors)
Extinguish the fire
when it is safe to
do so
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Pull the pin
Aim the nozzle at
the base of the fire
Squeeze the handle
Sweep the nozzle
from side to side
Workplace $400
What should you do in
the event of a hazardous
material spill?*
Answer
* Material more hazardous than
cafeteria food, but less hazardous
than anthrax
Answer Workplace $400
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Rinse exposure with water
Post warning signs
Cordon off area
Consult Material Safety Data Sheet
(MSDS) or call Hazardous Material
Safety Office
Workplace $500
What are code pink, code
white, code orange, code
gray, and code triage?
($100 per correct answer)
Answer
Answer Workplace $500
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Code pink: infant / child abduction
– The number afterwards refers to the age
of the child, e.g. Code pink 3
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Code white: pediatric code blue
Code gray: bomb threat
Code orange: hazardous material or
radiation spill / exposure
Code triage: disaster
Documentation $100
How do you document in
your procedure note that
you confirmed the correct
identity of the patient, and
the correct site of the
Answer
procedure?
Answer Documentation $100
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Document that a “time out”
was done (check box on
procedure note area of 253
form)
Documentation $200
How would you write the
order for 100 mg of Motrin
to be given to a 10 kg
child PO?*
Answer
* Answer is NOT
“with a pen”
Answer Documentation $200
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Motrin 100 mg = 10
mg/kg PO now
Must put mg/kg
(Date and time order, of
course)
Documentation $300
What’s wrong with this
order?
Motrin 600 mg PO q 6-8
hours prn pain (standard
adult dose)
Answer
Answer Documentation $300
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No range orders allowed
(No range in doses, no range
in time intervals)
Documentation $400
Which is acceptable?
Answer
Answer Documentation $400
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C
Signature
Last name legibly spelled out
Degree (MD, RN, PNP, etc.)
Identification number
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Documentation $500
What’s the “fifth vital sign”
that we document on ALL
patients, and where do we
document it?
Answer
Answer Documentation $500
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PAIN score
PAIN score
PAIN score (am I
getting through?)
Pre-printed pain
scales on 1st AND
3rd page of 253s
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GOALS
Pain med w/in 30min
Reassess w/in 30min of
IV/IM pain med, w/in
60min of PO
Pain score < 4 at d/c or
pain med for home
Potpourri $100
True of False:
Answer
A minor sibling may translate for
the parent if the minor is 13 years
old or older, clearly fluent in both
languages, and the parent and
minor consent to using the minor
as an interpreter
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Answer Potpourri $100
So VERY VERY False!
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Parent
“El bebe tiene mucho fiebre, hasta
ciento siete, y no come nada,
nunca, en todo su vida, (esos
Cheetos son la primera comida de
todo su vida), y tiene fiebre por
dos o tres meses, y le duele todo
su cuerpo, y tiene ronchas y grippe
y tos y nausea y diarrea…”
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Sibling Interpreter
“Tiene fiebre?”
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“Yes”
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Potpourri $200
Does Harbor have a
mission?
Answer
It’s not “To get our
residents more sleep
and more money.”
Answer Potpourri $200
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Mission: to provide high quality,
cost-effective, patient-centered
care through leadership in medical
practice, education and research.
Potpourri $300
What quality performance
data are collected in your
area, and how are you
involved?
Answer
Answer Potpourri $300
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Residents perform peer review of
AED and PED charts for pain
assessment and management. The
data are collated and shared on a
quarterly basis, and individual
residents also receive a report of
how they performed. Also, chart
review 8am in the PED.
Potpourri $400
Dr. X is starting his shift in the PED. He walks
down the hall, Starbucks in hand, and waves
“hi” to the nurses and clerk. He rounds the
corner, going through the propped open door
to stand in front of the board. He notes that
there are 2 patients with the same initials on
the board. He dumps his empty coffee cup in
the trash, sets down his trusty Harriet Lane
Handbook on the counter, and picks up a
chart. Where’s the JCAHO violation?
Answer
Answer Potpourri $400
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Only special fire doors may
remain open. Doors may not
be propped open (including
the 2 doors on either side of
the PED board).
Potpourri $500
A two-parter:
Answer
1) How do you know a piece of
equipment (e.g. defibrillator,
ultrasound) is okay to use?
2) What does the pink tubing around
the IV pole on the code cart mean?
Answer Potpourri $500
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Check on the equipment for a dated
sticker that it has been serviced by
mechanical.
Pink signifies a “combination cart”
which has supplies for both pediatric
and adult codes.