JCI Accreditation

Important Information
&
Frequently Asked Questions
 “
Assessment of Patients (AOP)
”
What is the goal of assessment/reassessment?

 To understand the care the patient is seeking

 To select the best care setting for the patient
 Identify and prioritize patient care needs.
 To understand the patient’s response to any previous care.
 To reach initial medical diagnoses; 1ry & associated conditions
 To reach nursing needs/conditions that require care,
interventions, or monitoring.
Who participates in patient assessment?

 Multidisciplinary care team; medical, nursing, clinical

nutritionist, physiotherapist, and other healthcare
professional staff.
What is the minimum content of patients assessments?

 Physical status  Socioeconomic status

 Pain  Educational needs
 Fall risk + if admitted
 Psychological status  Bed sores risk assessment
 Nutritional status  Discharge planning
 Functional status
What is the validity of the initial assessment?

 If assessment is greater than 30 days, repeat examination.

When must the admission assessment be completed?

 Physicians’ assessment start within 1 hour from

physical admission and documented within 24 hours
 Nursing assessment starts as early as possible
When is the patient reassessed?

 Nursing Reassessment includes:

1. Overall case reassessment every shift / in nursing notes
2. Vital signs / not more than 4 hours
 Physicians’ reassessment in progress notes at least
once daily or more.
Initial assessment forms
Specialized initial assessments
Reassessment forms
How does our hospital deal with patient’s pain?

 Patients have the right for pain assessment and management

 All our inpatients & outpatients shall be screened for pain.
 Physicians and nurses screen + assess pain initially.
 Nurses inform physicians about any patient experiences pain.
 Nurses routinely reassess patients’ pain with vital signs.
 Patients are educated about pain assessment & management
How is a patient’s level of pain assessed?

 Weuse a pain scale appropriate to the patient age,

cognitive abilities, and cooperation
Surveyor questions related to pain ..

 How do you involve patients/families in pain management?

 How do you know a child is hurting?
 What did you do for the pain?
 How do you know that what you did was effective?
 If it was ineffective, what did you do? Can you show me
your documentation?
What are your responsibilities related to pain
assessment and management?
 “
Patient and Family Education (PFE)
”
Who is responsible for patient and family education?

 All members of the health-care team; Multidisciplinary.

When are patient/family education needs determined?

 Initially at
the time of admission, and subsequently
throughout the patient’s stay
What doctors shall inform patients and families ?

 Medical conditions and any confirmed diagnosis

 The planned care and treatment(s) including; Pain
Management and Safe use of Medical Equipment, if any.
 The expected outcomes of care.
 Any unanticipated outcomes.
 Discharge Planning
How patient education occurs at your hospital?

 Assessment of patient/ family educational needs done by

nurses including ability and willingness to learn and barriers
 Multidisciplinary education occurs.
 Documentation in the Patient & Family Education (PFE)
form
 “
Care of Patients (COP)
”
Do you use any guidelines or clinical pathways in
your department?

 Appendectomy  Lower segment CS

 Lap Cholecystectomy  Children Acute Bronchial Asthma

 DKA  Upper GIT Bleeding

 Sepsis resuscitation  Uretero-renoscopy

How is the patient plan of care developed?
Why we have a Rapid Response Team (RRT)?

 Asan early response to changes in a patient’s

condition by specially trained individuals.
 According to Early Warning Signs (EWS)
A 4 steps Rapid Response Team process?

1- Initiation of the Process

 Nurse discovers patient deterioration
 She will initiate the Process.
 Call the treating physician/ICU physician.

2- Treating physician/ICU physician

 The only authorized to invite RRT by calling 1111
 Operator will direct RRT to the patient room by announcing twice
(Code Rapid .. patient room x .. floor x)
A 4 steps RRT process?

3- RRT including the treating physician will assess the Patient to:
 Implement code blue practice, if needed
 Transfer the patient to ICU
 Alter the care plan of the patient
 Continue with current care plan of the patient.

4- The RRT call and activities documented in nursing note

Adults Early Warning Signs

1- Respiratory Rate < 10 > 25

2- Oxygen Saturation < 90

3- Heart Rate < 50 > 120

4- Systolic Blood Pressure < 80 mmHg > 200 mmHg

5- Core Temperature < 35 > 39

For two
6- Urine Output if the patient is catheterized < 30 ml/hr > 200 ml/hr consecutive
hours

7- Pain Score >8

8- Consciousness level Sudden deterioration of consciousness level

 Pediatric Early Warning Signs

From To
Behavior Irritable Lethargic/confused reduced response to pain
Pain score >6
Grey Or CRT 4 seconds Grey, mottled Or CRT 5 seconds or more
Or
Circulation Tachycardia 20 above normal rate Bradycardia Or Tachycardia of 30 Above normal rate
Or Or
SaO2 85-90 SaO2 below 85
5 below normal parameters with Sternal recession,
>20 above normal Parameters
Tracheal tug
Or
Or
Respiratory Using accessory muscles
Grunting
Or
Or
40% FiO2 Or 6+liters/min
50% FiO2 Or 8 liters /min
Surveyor questions related to RRT ..

 Who should contact the Rapid Response Team?

 How do you contact the Rapid Response Team?
 What should you educate your patients regarding Rapid
Response Team?
High risk patients and high risk services

 Emergency patients.  Patients on restraints

 Patients on life support  patients on dialysis.

 Comatose patients  patients receiving chemotherapy

 Patients with communicable disease  vulnerable patient populations

 Immune-suppressed patients
When to do patient restraint?

 Based on individual patient assessment.

 Only when alternative methods have failed such as:
 Increased observation.
 Altered environment.
 Communication.
 Evaluation of medication for pain, anxiety, agitation & delirium.
 Offer toileting or assess elimination needs at least.
 Offer food and fluids for those who can take oral nutrition.
Who can initiate a restraint?

 Physical restraint order shall be written by the physician.

 The PRN orders shall not be accepted.
 verbal/telephone orders not accepted if not emergent.
 Nurse may apply a restraint in response to emergencies
 Inform physician as soon as possible to evaluate patient
and write the order.
What is the validity of a restraint Order?

 Initial orders
for physical restraint shall be limited to
24 hours only.
What must the restraint order include?

 Restraint order.
 Indications for restraint
 Observation of the patient during restraint.
Do you have vulnerable patient at your hospital?

 Elderlyand /or frail

 Dependent patients
 Children
 Disabled individuals.
 Comatose
 Terminally ill.
 Immune-compromised.
Assessment and reassessment End of Life Care includes

 Once physician decides the patient is terminally ill, he/she

will write “Terminal patient for palliative care” in
Doctor Orders Form to initiate the process of care
“assessment, re-assessment and care planning”.
Assessment and reassessment End of Life Care includes

 Symptoms as nausea and respiratory distress.

 Factors that alleviate or exacerbate physical symptoms.
 Current symptom management and the patient’s
response.
 Patient and family spiritual concerns or needs.
Assessment and reassessment End of Life Care includes

 Patient and family psychosocial status.

 The need for an alternative setting or level of care.
 Survivor risk factors, such as family coping mechanisms
and the potential for pathological grief reactions.
N.B. Survivor risk factors: Chances for surviving family members or other loved ones to
experience difficulties with the death of a loved one.
What are the Core Principles of End of Life Care?

 Patients areassessed as frequently as necessary to

identify symptoms.
 Symptoms assessment and appropriately manage.
 Treated with dignity and respect.
 Patients and staff are educated about managing
symptoms.
Care plans
Where is the nearest crash cart to your
department/location?
 “
Management of Information (MOI)
”
Proper Documentation in Medical Records

 Complete.
 Legible.
 Chronological entries.
 All entries are to be signed, dated and timed when they are written.
 Name and Signature,
 Minimum requirement: at least 2 names plus ID number.
 Stamp shall be used with signatures, not to replace signatures.
 Date, in the day-month-year sequence.
 Time, in military manner.
Proper Documentation in Medical Records

 Ifa late entry is made, write “Late Entry” and the actual time
of the entry.
 Do not leave any blanks. At least, you can write NAD or NA.
 For multiple choices parts of the forms, just tick positive parts
and leave negative parts blank. X is not allowed as per
organizational P&P.
 Use approved abbreviations only.
 Don’t use list “Do-not-use” Abbreviations Symbols
Correction of Errors

 If an error (a word, a line or even a whole paragraph), single

line will be drawn through the error, i.e. (word).
 In any space nearest to the line with the error:
 Write the capital letter “E” standing for “error”
 Record the correct information.
 Write your ID number or stamp according to available space.
Correction of Errors

 Never erase or paint out the error so that it is not visible.

 Correction fluid cannot be used in amending any
report/document in the medical record.
Don’t
 Don’t write any order in progress notes
 Don’t write any unapproved abbreviation
 Don’t stop any medication without sign and date, time
 “
Staff Qualifications and Education (SQE)
”
Job description

 All Staff hadgeneric job descriptions

 Every staff member signed a copy of a recently reviewed
job description. Copy present in your file in HR.
 Every staff member should know his job responsibilities,
sign a copy of a recently reviewed job description. Copy
present in your file in HR.
Hospital Orientation

 Orientation: a process of introducing, familiarizing with

and adapting of the new hires / existing staff.
General Orientation:

 Organized by training department and presented by

general orientation group.
 Is a two day program that is held in a conference room.
 All new employees must attend orientation before actual
work.
 Existing employees must complete orientation according
to orientation plan.
Department Orientation:

 Department orientation coversall department functions.

 Done by head of department or his designee.
Staff Evaluation

Staff evaluation types:

 Initial Evaluation, during initial 2 weeks.
 Probation Evaluation, after 90 days
 Annual Evaluation, after 1 year
 Ongoing Monitoring and Evaluation, every year.

 All these evaluation types done by head of department.

Ongoing monitoring and evaluation

 The process of continuously accumulating and analyzing

data and information on the behaviors, professional
growth, and clinical results of medical staff members.
 It is done to physicians, nurses, pharmacist and
technician.
 It encompasses three general areas behaviors, professional
growth, and clinical results
Credentials

 Documents that are issued by a recognized entity to

indicate completion of requirements or the meeting of
eligibility requirements, such as a diploma from a medical
school, specialty training (residency) completion letter or
certificate, completion of the requirements of a medical
professional organization, a license to practice, or
recognition of registration with a medical or dental council.
Verification

 The process of checking the validity and completeness of

a credential from the source that issued the credential.
 Licensure, education/training and experience.
Privileging

 The determination of a medical staff member’s current

clinical competence and making a decision about what
clinical services the medical staff member will be
permitted to perform.
 Privileging is the most critical determination a hospital
will make to protect the safety of patients and to advance
the quality of its clinical services.
Clinical Privilege

A specific scope and content of patient care services that

authorized for a health care practitioner by a healthcare
organization, based on evaluation of the individual’s
credentials and performance.
 All Privileges are on Public share.