BEACHFEST 2013

BEACHFEST 2013

WELCOME

Regulatory Requirements and Radiology

A Win-Win Format for Patient Care

The Joint Commission(TJC)

Technologists Training

Licensure

Registration

Continuing Education

Diagnostic Areas Environment of Care

Equipment

Supplies

Environment of Care

A survey by the Joint Commission found building conditions so poor in Greater Southeast Community

Hospital in Washington, DC, that the conditionstriggered a preliminary denial of accreditation.

Contrast Media Receipt

Storage

Use

Health Insurance Portability &

Accountability Act(HIPAA)

HIPAA Business Office

Corridors

Diagnostic Areas

HIPAA

Twenty-seven employees from Palisades Medical Center were suspended without pay for allegedlylooking at George Clooney’s medical records after

he was in a motorcycle accident.

Departmental Responsibilities State Regulatory Requirements

Hand Hygiene

Infection Control

National Incident Management System

(NIMS)

Emergency Operation Plan Hospital Incident Command System

Critical Areas Communications Resources & Assets Safety & Security Staff Responsibilities Utilities Management Patient Clinical & Support Activities

World Health Organization

The Joint Commission has a World Health Organization (WHO) contract for global

field testing of the International Classification for Patient Safety (ICPS).

Patient Safety Goals

Improve the Accuracy of Patient Identification

Use at least two patient identifiers when providing care, treatment, or services.

Improving Communication Among Caregivers

For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and “read-back” the complete order or test result.

Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

Measure, assess, and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

Improve the Safety of Using Medications

Standardize and limit the number of drug concentrations used by the organization.

Identify and, at a minimum , annually review a list of look- alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs.

Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

Reduce the Risk of Healthcare-Associated Infections

Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care –associated infection.

Accurately and Completely Reconcile Medications Across

the Continuum of Care There is a process for comparing the patient’s current

medications with those ordered for the patient while under the care of the organization.

A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.

Reduce the Risk of Patient Harm Resulting from Falls

Implement a fall reduction program including an evaluation of the effectiveness of the program.

Encourage Patients' Active Involvement in Their Own

Care as a Patient Safety Strategy

Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

The Organization Identifies Safety Risks Inherent in its

Patient Population The organization identifies patients at risk for suicide. Note: This requirement only applies to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.

Improves Recognition and Response to Changes in a

Patients Condition Maintain processes for identifying and addressing changes in a patient’s condition while in the Radiology

Department.

Include changes in a patient’s condition and current patient status in hand-off communication.

The Organization Fulfills the Expectations Set Forth in the

Universal Protocol Conduct a pre-operative verification process as described in the Universal Protocol.

Mark the operative site as described in the Universal Protocol.

Conduct a “time out” immediately before starting the procedure as describe in the Universal Protocol.

Tracer Methodology

Objectives of Tracer Activity Follow course of care and services provided to the patient

Assess relationships among disciplines and important patient care functions

Evaluate performance of processes relevant to the individual

Tracer Methodology A Systems Approach to Evaluation

Traces a number of patients through the organization’s entire health care process

Identify performance issues in one or more steps of the process – or in the interfaces between processes

Process surveyors use during on-site survey

Customized to HCO

Survey across services and programs

Multi-level participation

Priority Focus Areas1. Assessment and Care/Services 2. Communication 3. Credentialed Practitioners4. Equipment Use5. Infection Control6. Information Management7. Medication Management8. Organization Structure9. Orientation and Training10.Patient Safety11.Physical Environment12.Quality Improvement Expertise and Activity13.Rights and Ethics14.Staffing

Tracer Activity Comprises 50-60% of on-site survey time

Approximately 90-180 minutes in length

Starts and ends in the department where tracer patient is located

No mandated order for visits to care areas

Tracer Process May Include Observation of direct care

Observation of medication process to include contrast media

Individual or family interview

Review of medical records

Staff interaction

Review of policy and procedures

Departmental tours

WHOSE JOB IS IT?This is a story about four people named

Everybody, Somebody, Anybody, and Nobody. 

There was an important job to be done.Everybody was sure Somebody would do it.

Anybody could have done it, but Nobody did it.Somebody got angry about that because it wasEverybody’s job.  Everybody thought Anybody

could do it, but Nobody realizedthat Everybody wouldn’t do it.  It ended up

that Everybody blamed Somebodywhen Nobody did

what Anybody could have done.

THANK YOU!

Have a Safe Trip Home!!