JCAHO Jeopardy
Kelly D. Young, MD, MS
Harbor-UCLA Medical Center
JCAHO
BASICS
PATIENT
SAFETY
$100
$100
$200
WORKPLACE
DOCUMENTATION
POTPOURRI
$100
$100
$100
$200
$200
$200
$200
$300
$300
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$400
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$500
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JCAHO Basics $100
What does JCAHO
stand for?
Answer
Hint: It’s not “Julie Comes And Hangs Out”
Answer JCAHO Basics $100
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Joint Commission on
Accreditation of Healthcare
Organizations
AKA “Yes, we can close your hospital and make
you seek new residencies”
JCAHO Basics $200
During the JCAHO survey, the
surveyors will talk primarily to:
A) The hospital administrators
B) The doctors and nurses
C) The patients
D) The LA Times
Answer
Answer JCAHO Basics $200
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B) YOU!
That’s why you’re playing this
game, right?
PS: “I would ask my supervisor” is
always safe if you don’t know the
answer.
JCAHO Basics $300
What is “tracer
methodology”?
Answer
Answer JCAHO Basics $300
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Surveyors analyze a hospital’s
systems by following individual
patients through their
hospitalization, evaluating
multiple care units,
departments, and services
rendered to the patient.
JCAHO Basics $400
What is HIPAA? Name
one way protected health
information is kept
Answer
private in your
department.
NOT HIPPO!
Answer JCAHO Basics $400
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HIPAA: Health Insurance Portability and
Accountability Act
States that PHI may only be used for purposes of
treatment, payment, healthcare operations
HIPAA trashcan for HIPAA sensitive documents
Log out of Orchid when done viewing track
No patient info laying around in work rooms
DON’T use “5150” or “OD” when discussing pts
Don’t discuss patients in hallways or elevators
Keep curtains and doors closed and don’t let
patients stare at resuscitations
JCAHO Basics $500
What is ORYX?
Bonus $100: name one
core measure of ORYX
Answer
Answer JCAHO Basics $500
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ORYX requires hospitals to collect and
submit chart abstraction or electronic clinical
quality measures data each quarter
New in 2015: hospitals can choose which 6
measure sets they wish to report
– Only Perinatal care remains mandatory
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ED measure set include 2 measures
– Median time from ED arrival to ED departure for admitted
patients
– Admit decision time to ED departure for admitted patients
More next slide
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Acute myocardial
infarction
Heart failure
Pneumonia
Surgical care
improvement project
Children’s asthma care
Venous
thromboembolism
Stroke
Hospital-based
inpatient psychiatric
services
Hospital outpatient
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Immunization
Tobacco treatment
Substance use
treatment
Per Clint: Harbor
reporting inpt
psych, ED flow,
adult immunization,
endoscopy, surgical
care, outpatient
Patient Safety $100
Name one of the 2015
National Patient Safety
Goals
Answer
Answer Patient Safety $100
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Identify patients correctly
Improve staff communication
Use medicines safely
Prevent infection
– Handwashing, central line infections, post-op infections,
prevent UTI s/p catheters
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Use alarms safely
Identify patient safety risks (suicidality)
– Left off of critical access hospital goals
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Prevent mistakes in surgery
– Correct side, place, procedure
Patient Safety $200
Name one way you reduce
the risk of health-care
associated infections in your
department
Answer
Answer Patient Safety $200
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Handwashing with soap and water before
AND after each patient contact
– Even if you used gloves
– Wash vigorously for 15 seconds
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Alcohol-based hand rubs may be used if
there is no visible soiling and C. diff is not
suspected
Use of artificial or long fingernails is
prohibited
LATHER UP!
Patient Safety $300
How do you improve the
accuracy of patient
identification in your
department?
Answer
Answer Patient safety $300
• I use TWO (2) (dos) identifiers when
providing treatment, administering
medications, collecting specimens,
discharging the patient
• Patient’s name
• Patient’s MRUN
• NOT patient’s room number or chief
complaint (e.g. the lac in room 6)
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Patient Safety $400
How are you improving
the effectiveness of
communication between
caregivers?
Answer
Answer Patient Safety $400
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Telephone orders are read back
Verbal orders are repeated back
Critical lab values and other test results are read
back
We use standardized abbreviations and avoid
certain unapproved dangerous abbreviations
Preliminary radiology reads in
Orchid – Overread by radiologist and we
we are notified of any disagreements
Patient Safety $500
Name 3 of the unapproved
abbreviations
Bonus: where are your
scheduled drugs
prescription pads?
Answer
Answer Patient Safety $500
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U or u (unit)
IU (international unit)
Ug (microgram)
1.0 (no terminal
zeros)
.5 (always use a
leading zero –
“always lead, never
follow”))
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X3d (for 3 days or for
3 doses)
TIW (three times
weekly)
qD or qoD (every
day, daily, or every
other day)
MS, MSO4, MgSO4
(morphine sulfate or
magnesium sulfate)
Bonus Answer: On my person at all times, or locked up
Workplace $100
Where are the fire
extinguishers in the AED
and PED?
BONUS:
Where’s the oxygen
shutoff valves in case
of a fire?
Answer
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Answer Workplace $100
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AED and RME
Fire extinguishers (they
are well marked with red
vertical sign on wall)
– Near/across from rooms 6,
10, 23, RME 17
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– Opposite trauma 6 and
room 10
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QI board
– By RN lockers
Oxygen shut off
– Opposite room 14, between
rooms 2 and 3, opposite
Trauma 7
Oxygen shut off
– Near radio room, room 19,
RME room 16, across from
trauma rooms 1, 2, 5
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PED
Fire extinguishers
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Fire alarm wall pull
– Opposite Trauma 7
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QI board
– Opposite room 3
Workplace $200
What color “code” would
you call if you had a violent
patient? Who would come?
Answer
Answer Workplace $200
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Code Green
Crisis Response Team
responds
Does NOT include police
officer
ED staff are still responsible
for the patient, and should
assist in restraint if necessary,
while attending to own safety
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Workplace $300
What do the RACE and PASS
mnemonics stand for when
there is a fire?
Answer
Answer Workplace $300
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Remove patients
and others
Alarm
Contain the fire
(close doors)
Extinguish the fire
when it is safe to
do so
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Pull the pin
Aim the nozzle at
the base of the fire
Squeeze the handle
Sweep the nozzle
from side to side
Workplace $400
What should you do in
the event of a hazardous
material spill?*
Answer
* Material more hazardous than
cafeteria food, but less hazardous
than anthrax
Answer Workplace $400
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Rinse exposure with water
Post warning signs
Cordon off area
Consult Material Safety Data Sheet
(MSDS) or call Hazardous Material
Safety Office
Workplace $500
What are code pink, code
white, code orange, code
gray, and code triage?
($100 per correct answer)
Answer
Answer Workplace $500
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Code pink: infant / child abduction
– The number afterwards refers to the age
of the child, e.g. Code pink 3
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Code white: pediatric code blue
Code gray: bomb threat
Code orange: hazardous material or
radiation spill / exposure
Code triage: disaster
Documentation $100
How do you assure that
you confirmed the correct
identity of the patient, and
the correct site of a
procedure?
Answer
Answer Documentation $100
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Do a “time out” and
document that it was done –
document this in the
procedure note
Documentation $200
What does the little M
mean on the Orchid track
and what do I do with it?
Answer
* Answer is NOT
“ignore and hope
it goes away”
Answer Documentation $200
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• Medical Screening Exam – every
patient needs one
• For physicians, click MSE to find the
form, and click the 2 boxes “definite tx
provider” and “please see chart”
Documentation $300
What’s wrong with this
order?
Motrin 600 mg PO q 6-8
hours prn pain (standard
adult dose)
Answer
Answer Documentation $300
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No range orders allowed
(No range in doses, no range
in time intervals)
Documentation $400
Which is acceptable?
Answer
Answer Documentation $400
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C
Signature
Last name legibly spelled out
Degree (MD, RN, PNP, etc.)
Identification number
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Documentation $500
What’s the “fifth vital sign”
that we document on ALL
patients, and how can we
improve in this area?
Answer
Answer Documentation $500
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PAIN score
SCREEN patients
and order meds
within 30 min of
pt arrival to ED
Prescribe or
suggest (in pt
instructions) pain
med on discharge
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GOALS
Pain med w/in 30min
Reassess w/in 30min of
IV/IM pain med, w/in
60min of PO
Pain score < 4 at d/c or
pain med for home
Potpourri $100
True of False:
Answer
A minor sibling may translate for
the parent if the minor is 13 years
old or older, clearly fluent in both
languages, and the parent and
minor consent to using the minor
as an interpreter
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Answer Potpourri $100
So VERY VERY False!
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Parent
“El bebe tiene mucho fiebre, hasta
ciento siete, y no come nada,
nunca, en todo su vida, (esos
Cheetos son la primera comida de
todo su vida), y tiene fiebre por
dos o tres meses, y le duele todo
su cuerpo, y tiene ronchas y grippe
y tos y nausea y diarrea…”
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Sibling Interpreter
“Tiene fiebre?”
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“Yes”
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Potpourri $200
Does Harbor have a
mission?
Answer
It’s not “To get our
residents more sleep
and more money.”
Answer Potpourri $200
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Mission: to provide high quality,
cost-effective, patient-centered
care through leadership in medical
practice, education and research.
Potpourri $300
What quality performance
data are collected in your
area, and how are you
involved?
Answer
Answer Potpourri $300
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Look at the QI
boards in AED and
PED to see
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Medication errors
Fall prevention
Sepsis data
Pain management
Timeouts for nonemergent procedures
– Procedural sedations
reviewed
– Ebola screening
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Individual cases
highlighted for
opportunities in
improving medical
management are
reviewed for EDQI
committee, and may
be presented in an
M&M
– Residents help
prepare presentation
Potpourri $400
Dr. X is starting his shift in the PED. He walks
down the hall, Starbucks in hand, and waves
“hi” to the nurses and clerk. He rounds the
corner, going through the propped open door
to stand in the docbox. He logs on and notes
that there are 2 patients with the same last
name on the track. He dumps his empty coffee
cup in the trash, sets down his trusty Harriet
Lane Handbook on the counter, and nudges
the sleeping intern. Where’s the JCAHO
Answer
violation?
Answer Potpourri $400
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Only special fire doors may
remain open. Doors may not
be propped open (including
the 2 doors on either side of
the docbox).
Potpourri $500
A two-parter:
Answer
1) How do you know a piece of
equipment (e.g. defibrillator,
ultrasound) is okay to use?
2) What does the pink tubing around
the IV pole on the code cart mean?
Answer Potpourri $500
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Check on the equipment for a dated
sticker that it has been serviced by
mechanical.
Pink signifies a “combination cart”
which has supplies for both pediatric
and adult codes.
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