Kiley Bybee-Francque, CJCP Assciate Directr Jint Office fr Cmpliance 1
Abut Me 2
TJC Extensin Survey fr Child Health Specialty Clinics* Cmmissin n Accreditatin f Transprt Services (CAMTS) The American Assciatin fr Accreditatin f Ambulatry Surgery Facilities(AAAASF) Rural Health Survey Sigurney and River Crssing* Jint Cmmissin Advanced Certificatin Palliative Care FDA Visit IVF and Cellular Therapies* Jint Cmmissin Advanced Certificatin Ventricular Assist Device Jint Cmmissin UICMS Labratry Survey* IDIA Dialysis In-Center, Hme, & Pediatrics* Jint Cmmissin Fr-Cause Credentialing and Infrmed Cnsent* IDIA Incident & Cmplaint Investigatin Patient Rights* IDIA Dialysis In-Center, Hme, & Pediatrics Revisit* IDIA Fllw-up Patient Rights Survey* NCQA Patient-Centered Medical Hme Recgnitin FDA Visit DeGwin Bld Center* TJC Cmprehensive Strke Survey Cmmissin n Accreditatin f Transprt Services (CAMTS) Revisit fr Grund Transprtatin ACS Adult & Pediatric Trauma Review Pulmnary Hypertensin Assciatin Care Center Review EMTALA Investigatin* ACS Burn Center Re-verificatin Survey IDIA Incident Patient Rights* TJC Lab Survey* TJC Palliative Care Survey*
Upcming Surveys: Anytime: IDIA r TJC can survey the hspital at any time. IDIA is n site frequently fr investigatins int cmplaints and self-reprted incidents. IDIA Dialysis Grinnell, Washingtn, and Muscatine (anytime) CMS Transplant Certificatin Survey (anytime) TJC Artic Aneurysm and Valve Repair and Replacement Survey (March, 2016) TJC VAD Survey (July, 2016) TJC UICMS Lab Survey (August, 2016) TJC Hspital Survey (September, 2016) Fundatin fr Cellular Therapy (Fall 2016) TJC UICMS Ambulatry Survey (December, 2016)
What is The Jint Cmmissin? 5
Healthcare accrediting rganizatin By achieving accreditatin: UIHC demnstrates a cmmitment t prvide safe, quality care t its patients. CMS and all insurance prviders allw us t bill fr ur services UIHC can btain annual licensure f beds thrugh the State f Iwa Allws training prgrams t take place
Almst all surveys are unannunced Survey length 1 day t 5 weeks Patient Tracer Methdlgy fr assessment Fcus n patient flw thrugh the system f care Fcus n critical systems and wrk flw prcesses Fcus n "Patient Stry" The Jint Cmmissin fcuses n Natinal Patient Safety Gals
Surveyrs are allwed t g t any area f the hspital Surveyrs are allwed t review patient infrmatin They will ask t speak with the staff members invlved with caring fr a chsen patient Assume they will want t talk with yu: Have cnfidence in yur respnse It is an pen bk test and yu can ask thers fr assistance if yu d nt knw the answer
Shw me yur dcumentatin. Tell me hw yu cmmunicate yur plan with nursing. Shw me where the nurses dcumented the vitals. What is yur rle in patient safety (i.e., NPSGs)? What makes yu cmpetent in yur rle and hw yu were riented in that rle (i.e., licensure, yearly cmpetencies)? Hw is care crdinated and cmmunicated with ther disciplines (i.e. care planning)? What yu wuld d in an emergency(i.e. fire)? Hw d yu supprt patient rights? What are yur Perfrmance Imprvement Prjects n yur unit?
Endscpe prcessing and ther sterilizatin, high level disinfectin and strage issues Generatr testing issues Quality Assurance/Perfrmance Imprvement nt inclusive/integrated Clinical alarm issues Medicatin management safe administratin, rdering issues, etc. Restraint and seclusin issues
Ht Tpics fr Physicians Histry and Physicals Bld Cnsents Hand-Off Cmmunicatin Advanced Directives Pst-Operative Nte Infrmed Cnsent
Histry and Physicals 24 hurs after admissin N mre than 30 days prir t prcedure Update required immediately prir t prcedure (r I have examined the patient nted)
Bld Transfusin Cnsents Transfusin Cnsent fr patients during an perative prcedure is 100% cmpliant Elective Transfusins dcumentatin missing Audits shw we are usually at 90%, need t reach 100%
Immediate pst-p nte must be entered befre patient taken t next level f care Primary surgen and assistants Prcedure perfrmed and descriptin f prcedure findings Estimated bld lss Specimens remved Pstperative diagnsis Full Operative Nte must be dictated within 24- hurs pst prcedure.
Off-service t n-service handff by physicians Off service patient status reprt by the respnsible physician t the n service physician is required Transfer f a patient frm the OR t a pst-perative area Requires a reprt frm the anesthesilgist t the pst-perative caregiver
Must be cmpleted fr all prcedures being perfrmed Signed, timed, and dated Prcess E-Signature Prject
1. Never prvide an imprmptu hspital tur. Escrt surveyrs directly t the apprpriate place/persn. 2. Patient care cmes first. If yu need t leave a surveyr t check n a patient, be plite and ffer t meet the surveyr again as sn as pssible. 3. Be flexible. Yu may be interviewed nce, multiple times, r nt at all. Regardless, be ready. 4. Surveyrs may bserve yu smetimes withut warning. Fcus n prviding quality patient care and fllwing prper prcedures, and remember HAND HYGIENE. 5. Ask the surveyr t repeat r clarify a questin when yu are unclear f what they are asking and when yu need additinal time t think f yur respnse. If yu dn t knw the answer t a questin, be able t shw the surveyr where yu can find it (i.e. the plicy manual).