Transcript Slide 1

The Karmanos Cancer Center
Regulatory Readiness (for Non Clinical Staff)
2012
Department of Quality and Regulatory Affairs
Barbara Ann Karmanos Cancer Center
Regulatory Readiness
• Karmanos Cancer Center (KCC) is committed to
delivering high quality care.
• KCC is committed to keeping our patients safe.
• KCC maintains a constant state of readiness for any
regulatory survey that may occur.
• Each staff member plays an important role in helping
KCC achieve and maintain this constant state of
readiness.
• KCC Patients and families may contact The Joint
Commission regarding quality concerns.
Regulatory Readiness
• The Joint Commission can conduct an unannounced
survey at any time.
• The survey team will use a process called “tracer
methodology” to follow patients through hospital
processes.
• Surveyors will look at the care, treatments and services
provided by individual departments, as well as how we
work together.
• The Joint Commission National Patient Safety Goals are
required standards of care that protect patient safety and
are part of patient care daily routines
Tracer Methodology:
What is it?
• Tracer Methodology follows (traces) a patient through their
hospital stay
– Surveyors may start a “tracer” at any point of a patient’s stay.
• Tracer Methodology surveys from a patient perspective
– Surveyors will speak with patients
• Tracer Methodology evaluates patient care and safety at the
bedside
– Surveyors will ask staff questions regarding:
• How they deliver safe care
• What their processes and policies are,
• How do the staff know if they are doing a good job?
How can you get ready now?
• Stay updated on your department’s or unit’s
policies
• Stay updated on your department’s or unit’s
process improvement initiatives
• Know the common items: (refer to your badge
card)
– Memorize how to respond to a fire: R.A.C.E. and
P.A.S.S.
– The emergency codes
– The KCC mission statement
– The National Patient Safety Goals
Regulatory Readiness
• 2012 National Patient Safety Goals
(NPSG):
– Defined by the Joint Commission to help
accredited organizations address specific
areas of concern regarding patient safety.
– Each goal has recommendations
– Each year the goals and recommendations are
re-evaluated, re-prioritized and modified
2012 NPSG
“Identify Patients Correctly”
•
Use at least two patient identifiers when
–
–
•
Providing any treatments or procedures
Identifying a patient in any way (transporting, calling back from a
waiting room, etc…..)
Patient identifiers
–
–
Can be a patient name, MR number, or date of birth
Never a room number
2011 NPSG
“Improve Staff Communication”
•
Report results of critical tests & diagnostic procedures on a
timely basis
–
Results of critical tests are reported to authorized clinical staff
2012 NPSG
“Use Medicines Safely”
•
Label all medications, medication containers and other
solutions on and off the sterile field in peri-operative and
other procedural settings.
2012 NPSG
“Use Medicines Safely”
•
Maintain and communicate accurate patient medication
information.
– Obtain a list of all medications that a patient is currently
taking when they are admitted.
–
Compare the list of medications that the patient was taking
on admission with the medications ordered while in the
hospital. Resolve all discrepancies.
–
Provide the patient or family with an accurate list of all
medications that they should be taking when discharged.
–
Explain the importance of managing their medication
information to the patient or their family.
2012 NPSG
“Prevent infections”
•
Comply with hand hygiene guidelines.
–
WASH YOUR HANDS with soap and water for 15 seconds or
use alcohol hand gel upon entering and exiting a patients room
and after use of gloves
–
KCC monitors compliance with hand hygiene through direct
observation.
•
Implement evidenced-based practices to prevent
infections due to multi-drug resistant organisms (MDRO).
–
Follow policies and practices aimed at reducing the risk of
transmitting MDROs.
2012
“Prevent Mistakes in Surgery”
•
Universal Protocol applies to all operative and other invasive
procedures that expose patients to more than a minimal risk.
•
These include procedures done in settings other than the
operating room such as in the Infusion Center, Ambulatory
Clinics, Radiation Oncology Center, and in Patient Rooms.
•
The Universal Protocol includes:
–
–
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Pre-procedure verification of correct patient, correct procedure,
correct site/side, needed implants / medications.
Site marking as appropriate.
“Time-out” immediately before starting the procedure to re-verify
correct patient, correct procedure, correct site/side, implants and
medications.
Are You Ready?
• For each National Patient Safety Goal:
– ask yourself what the hospital process is, and how well is your unit or
department doing?
• Always wear your hospital ID badge
• Be aware surveyors may stop to talk to you any time during
a survey.
• Be proud of your job and your role in providing safe, high
quality patient care.
• Know your department’s “process improvement initiatives”
and where to find your PI results
• Know how to find KCC policies and refer to them if needed.
Regulatory Talking Tips!
Always
• Be positive in your response to questions
• Make eye contact and be professional
• Respond by referring to KCC policies for processes…. e.g.
“Our process is……”
“Our policy states we …..”
• Tell the surveyor what you know and then refer them to the
correct person when unsure of information
• Just answer the question asked…..
• Use your department resources to answer surveyor’s questions.
– For example, use reference binders, “Survey Readiness
Guide” or process improvement bulletin board (if your
department has one).
Regulatory Talking Tips!
• Don’t be negative in your response
• Don’t respond by saying
“This is how I do it…others may do it differently” or
“We always do it this way….”
• Don’t wait to get ready: Be prepared early and
use your resources.
• Don’t worry! Respond professionally and
prepare early.
Regulatory Readiness
Summary
• Karmanos Cancer Center (KCC) is committed to delivering
high quality care.
• KCC keeps our patients safe
• In order to succeed in delivering high quality care, KCC
maintains a constant state of readiness for any regulatory
survey that may occur.
• Each staff member plays an important role in helping KCC
achieve and maintain this constant state of readiness.
• Joint Commission National Patient Safety Goals are part of
the constant state of readiness in which staff must
incorporate into their daily routine.
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