JACHO survey

June55Baby · Sep 1, 2004

Haven't been through JCAHO Survey this year, but from other hospitals who have JCAHO is honing in on:

National Patient Safety Goals (Pt Identification, Prohibited Abbreviations, Read Back of Critical Test Results and Verbal Orders, Universal Protocol for Invasive Procedures, Concentrated Electrolytes, Free Flow Protection on IV Pumps, Hand Hygiene, etc)

H&P on chart prior to procedure

Pain assessments and reassessments

Staffing Effectiveness

Infection Control (sterilization of supplies, hand hygiene, out dated supplies/drugs)

HIPAA

Staff Competency

Interdisciplinary Care

Nutrition and Functional Screens

Point of Care Testing

Security of Medications

Infant security

Any FMEAS or RCA as of Sentinel Events

PI Data - Core Measures

Advance Directives

Consents including Risks, Benefits, and Alternatives

That's all I can think of off the top of my head.

Good luck on your survey!

SmilingBluEyes · Sep 1, 2004

Let me see, we just had our survey this summer......

Security is a huge issue......security of infants/ units. Do you have a locked-down unit, special security bands on babies, etc. If you do, show it off and be sure you are familiar with "code pink" procedures (or whatever you call infant abduction).

Also be familiar and ready for Disaster Drills. Know where your disaster manual is and be familiar with procedures.

also securing meds, under double lock for narcs. Also secure your needles, syringes, etc away from public access of any sort. Anything to do with drugs, secure it.

Make sure you watch those abbreviations, if in doubt, spell it out. e.g. MAGNESIUM SULFATE not, MGS04 etc....UNITS, not U

Chart audits were done as usual....make sure all is charted well!

Surgical/Epidural "Time-outs"----e.g. you take time out to make sure you have the right patient, right site, etc. YES this INCLUDES epidurals, tubals, csections, we had to do a "time out" for each of these cases, a written sheet, witnessed by two nurses prior to proceeding with each case.

Meds........they are really looking for us to be sure "5 rights" are done....they like that e-mar is being used in our hospital, e.g, scanning the med label to patient ID band. They are really into these safety issues, big time!

This is most of what I remember. It's like always. Making sure you are familiar with P/P and up to date. If you do well from the start, they tend not to dig too far I have found. If not, they dig deeper. Know your stuff and show off what you KNOW you do WELL! Good luck!

babies_r_us, RN · Sep 2, 2004

We just completed our and can breathe a sigh of relief (and have a glass of water at the nurses station!!)

Some of the items that he was impressed with were "R/C "for repeated and confirmed on the verbal orders and telephone orders, and they were impressed with our new pathways that we use.

He wanted to know about our clientele and number of c/s's, number of gyne patients, number of fetal demise etc. Our director had to help with this. One area that he wanted improvement was a cupboard for our cleaning solutions. Right now we keep them under the sink in the dirty utility room and that wasn't good enough.

He pulled a c/s chart and went thru page by page with the nurse caring for the patient. It was very informal and the nurses were not intimidated by him. WE do have a new, expensive security system and he wasn't even impressed with that. It even alarmed for several minutes in error and he didn't even pick up on it luckily!! We installed it days before JCAHO came and still had "bugs" to work out. I was not in on the survery but can talk with the nurses to give more comment on it. Good luck, Sharon

SmilingBluEyes · Sep 2, 2004

yes good points...they DO pick patients who have SEVERAL DAY stays and follow them from the admissions process through discharge, going through the chart with a fine tooth comb. I almost forgot....

OH and YES make sure you chart "read back telephone/verbal order" when taking orders. VERY important.

HazeK · Sep 6, 2004

Any other suggestions from those that read this thread??

'Cuz, ready or not, here THEY come! LOL!

Haze :chuckle