Educating Your Staff

JCAHO Hot Points

1
 Patient Rights/ Org. Ethics
• Know Ethics Committee
• Know Rights are posted in lobby
• Know privacy concerns
• Telephone confidentiality
• Medical records left unattended/open

2
 Assessment of Patients
• How we assess for nutrition/rehab/soc svc.
• Waived Testing POC (manual)
• Monitoring for victims of abuse
• Nurses notes (your documentation)
• QC checks
• Assessment of pain

3
 Care of Patients
• Scope of Practice
• Checking exp dates of meds, etc
• Security of meds, carts ,etc
• Pain follow up and treatment
• Informed Consent (NURSE ONLY WITNESS)
• Individualized plans of care

4
 Education of Patients & Family
• Education nurse at each facility
• Evidence of education
• Address communication barriers
• Use of community resources avail to patient
• Evidence of ongoing education
• Follow up well documented in chart
• Aware of learning needs

5
 Continuity of Care
• Appointment avail in timely manner
• Referral tracking for follow up notes
• Transfer of patient to facility w info
• Do referrals meet patient needs
• VHS Transfer Form

6
 Environment of Care
• Safety Officer at each facility
• Proper medical waste
• MSDS
• Safety issues (infant/peds/confused/elderly)
• Security (meds/computers/Med. Rec.)
• Hallways clear
• Extinguishers checked Q3 mos.; Drills Q quarter
• Monitoring of Sterilizers
• 18” from ceiling, 8”from floor, 2 “ from wall
• Crash cart checks, Emergency Preparedness
7
 Human Resources
• Education of Staff, and New Staff
• Licensure Verification of Staff
• Age Specific Competencies
• Continuing Education Offered
• Timelines in PIPS are followed
• Goals in PIPS are met or shown effort
• Staff Competencies

8
 Management of Information
• Charting/ documenting
• Nursing documentation importance
• Reports written after procedure and not end of day
• Get info. back from specialists
• Problem list complete by 3rd OV, allergies by 1st OV
• Med. Rec. Review (Peer Review/ Quarterly reports)

9
 Infection Control
• Everyone’s responsibility
• Reporting of Infections (VDH binder)
• Handwashing/ No eating drinking in patient care areas
• Sterile vs. aseptic; Needles, Linen, Equipment
• Cleaning between patients & General good housekeeping
• PPE (personal protective equipment) use
• PPD screening appropriate, actions taken for outbreaks
• What do YOU do to help w/ infection control?
• Sterilization logs/spore testing for autoclaves
10
 Leadership
• Uniform performance of patient care guidelines
• PI activities participation
• Planning future PI initiatives

11
 Improving Organization
Performance
• PI projects
• Focus PDCA/ Juran
• Measuring outcomes
• Benchmarking tools
• Opportunities Upcoming

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