quality issues

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I am involved in the monitoring of quality assurance for our ER dept and I am wondering what other hospitals are monitoring. Maybe what are hot issues out there that JCAHO maybe looking for. Thanks for any ideas or suggestions

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The hot topics in our ED right now for QA monitering are Conscious Sedation and Restrain/Seclusion issues. Both are JACHO driven and were hot topics during recent JACHO reviews.

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JCAHO really dug into our use of conscious sedation in the ED. They really didn't address restraint use in the ED, they reserved that for the other nursing units.

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conscious sedation is a definite - JCAHO is also looking for interdepartmental projects - this can be done with pharmacy around conscious sedation - patients leaving before being seen by the MD/AMA's - age specfic competencies were an issue - there must be a mechanism for skill testing, knowledge testing is not sufficient - they are still looking at crash carts and how they are checked - they want to see a log of daily checks and locks on the carts - good luck

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We just had our review and the hot topics were the crash carts and how you log restock and lock the carts. Another hot topic was decontamination. Be sure you have policy in place for decontamination. A good buzzz word is "multidisciplinary" Also they have changed quality assurance to performance improvement. QA to PI. Good Luck..

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One of the issues that is being tracked here is Patient Transfers. Proper documentation of the other facility's acceptance and stability of the patient is up there on the list. Anything short is a COBRA violation of course. Restraints and conscious sedation are always being looked at too.

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JCAHO visited us 2 weeks ago. Their main concerns as have been mentioned earlier were Conscious sedation, Process Improvement, Competencies, restraints. They were going to look at our drugs, but when the found out that we use the Pyxis system, they did not even want to go in the med room. They spent only an hour in our department, and talked only with the director, the medical director, and one charge nurse. Fortunately, we passed with flying colors. As my manager says, he is fluent in JCAHO speak...

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Important to payors as well are: compliance with door to antibiotic time for pneumonia, door to EKG time in chest pain patients, door to pain med in fractures and response to pain med documentation.

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Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
Important to payors as well are: compliance with door to antibiotic time for pneumonia, door to EKG time in chest pain patients, door to pain med in fractures and response to pain med documentation.

I think the OP was inquiring about JCAHO requirements - the ones you mentioned are CMS guidelines with the exception of addressing pain.

CMS guidelines are more of your "evidence based" treatment guidelines/protocols.

JCAHO is more about the "environment" of care and "safety" of the patient evironment.

Anyone feel free to comment/correct me if I'm mis-interpreting here.

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Specializes in Cardiac, ER.

Did you guys notice the dates on those posts??? Amazing how things never change...:)

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
Did you guys notice the dates on those posts??? Amazing how things never change...:)

LOL! Another fine gravedig/resurrection. But yeah ... some things don't change!

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LOL, didn't notice. Will have to pay more attention since it was mixed in with some more current posts.

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