Performance Improvement

alot of the same things....and chart reviews.......they are really looking at our pain assessments, too, and how we are addressing pain issues...as well as follow up!!!!!!

Pain assessment/reassessment, unapproved abbreviations and risk for falls are some of the things JCAHO are targeting on their recent surveys so we have been really watching those.

We are working on getting moms of preemies that go to the NICU to pump within 6-8 hours of delivery and then regularly after to get their milk established and to their little ones. It is working very well!

JCAHO just came to the hospital where I'm in my preceptorship... they of course did chart reviews (picked the one my preceptor and I did for our unit!), the word was that they were really looking for individualized care plans too (and we did in fact hear later that they commented on the individualization on ours).

Some of the broad things for ours is infant mortality, 3rd & 4th degree lacerations, and I think VBAC was one of ours but no one here does them anymore so that's moot. I'm not sure what else, I haven't heard any talk or seen reporting of anything else.

Yep individualized care planning is a biggie. We have all ours built into our computerized charting, however, we are woefully inadequate in addressing these items with any regularity at all. SO time-consuming, it's unreal.