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 $300 $300 $300 $400 $400 $400 $400 $400 $500 $500 $500 $500 $500 JCAHO Basics $100 What does JCAHO stand for? Answer Hint: It’s not “Julie Comes And Hangs Out” Answer JCAHO Basics $100 Return to Jeopardy 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 Return to Jeopardy 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 Return to Jeopardy 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 Return to Jeopardy 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 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 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 Answer continued Acute myocardial infarction Heart failure Pneumonia Surgical care improvement project Children’s asthma care Venous thromboembolism Stroke Hospital-based inpatient psychiatric services Hospital outpatient Return to Jeopardy 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 Return to Jeopardy Identify patients correctly Improve staff communication Use medicines safely Prevent infection – Handwashing, central line infections, post-op infections, prevent UTI s/p catheters Use alarms safely Identify patient safety risks (suicidality) – Left off of critical access hospital goals 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 Return to Jeopardy Handwashing with soap and water before AND after each patient contact – Even if you used gloves – Wash vigorously for 15 seconds 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) Return to Jeopardy Patient Safety $400 How are you improving the effectiveness of communication between caregivers? Answer Answer Patient Safety $400 Return to Jeopardy 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 U or u (unit) IU (international unit) Ug (microgram) 1.0 (no terminal zeros) .5 (always use a leading zero – “always lead, never follow”)) Return to Jeopardy 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 Return to Jeopardy Answer Workplace $100 AED and RME Fire extinguishers (they are well marked with red vertical sign on wall) – Near/across from rooms 6, 10, 23, RME 17 – Opposite trauma 6 and room 10 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 PED Fire extinguishers Fire alarm wall pull – Opposite Trauma 7 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 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 Return to Jeopardy Workplace $300 What do the RACE and PASS mnemonics stand for when there is a fire? Answer Answer Workplace $300 Remove patients and others Alarm Contain the fire (close doors) Extinguish the fire when it is safe to do so Return to Jeopardy 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 Return to Jeopardy 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 Return to Jeopardy Code pink: infant / child abduction – The number afterwards refers to the age of the child, e.g. Code pink 3 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 Return to Jeopardy 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 Return to Jeopardy • 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 Return to Jeopardy No range orders allowed (No range in doses, no range in time intervals) Documentation $400 Which is acceptable? Answer Answer Documentation $400 C Signature Last name legibly spelled out Degree (MD, RN, PNP, etc.) Identification number Return to Jeopardy 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 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 Return to Jeopardy 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 Return to Jeopardy Answer Potpourri $100 So VERY VERY False! 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…” Sibling Interpreter “Tiene fiebre?” “Yes” Potpourri $200 Does Harbor have a mission? Answer It’s not “To get our residents more sleep and more money.” Answer Potpourri $200 Return to Jeopardy 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 Look at the QI boards in AED and PED to see – – – – – Medication errors Fall prevention Sepsis data Pain management Timeouts for nonemergent procedures – Procedural sedations reviewed – Ebola screening Return to Jeopardy 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 Return to Jeopardy 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 Return to Jeopardy 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.