JCAHO A Constant State of Readiness

1. 2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future JCAHOA Constant State of Readiness How to Encourage Staff to Become Engaged and Involved While Focusing on Patient Safety Kenneth H. Belcher Boston University School of Medicine May 18, 2006 11:00-11:30pm

2. 5 STEPS TO READINESS • Explain/emphasize to staff/employees why JCAHO readiness is so important • Demystify what it means to be JCAHO ready • Actions to become JCAHO ready • Testing for readiness/compliance • Maintain readiness

3. STEP 1 Explain/ emphasize to staff and employees why JCAHO readiness is so important.

4. Step 1: Explain/Emphasize • For most hospitals, JCAHO is THE accreditation agency. • JCAHO accreditation allows hospitals to qualify for federal reimbursement. • JCAHO awards the score and ranks hospital with competitors. • As human beings, we perform best when there is a clear goal/measurement of what must be achieved. 2nd Annual Ellison Pierce Symposium Positioning your ORs for the Future 4

5. Step 1: Explain/Emphasize • Without the requirement for accreditation, there is little doubt quality would slip in each institution. • Uniform quality of care throughout the region could not be guaranteed.

6. STEP 2 Demystify what it means to be “JCAHO Ready”

7. Step 2: Demystify • What does it mean for the institution at large? • What does it mean for my department? • What does it mean for those I serve? • My fellow staff members? • My patients? • What does it mean for me to be ready?

8. STEP 3 Actions to be taken to become JCAHO Ready

9. Step 3: Act Commitment must start at the top of the organization: • Board of Trustees • Hospital President and Senior Management • Department Chairmen/ Chiefs of Service If there is not clear/obvious dedication at the top, readiness will be difficult to achieve and impossible to maintain.

10. Form a JCAHO Steering Committee Charge: • JCAHO Continuous Readiness Co-Chairs: • Vice President with JCAHO Oversight • JCAHO In-house Expert Membership: • Leaders of all JCAHO functions • Patient Rights and Organizational Ethics • Medication Management • Information Management • Infection Control, Surveillance and Prevention • Environment of Care • Human Resources • Medical Staff Leadership

11. Form a JCAHO Steering Committee Committee should: • Meet monthly • Review Chapter Standards • Chapter Chairs • Review PPR Status • Review Tour Team Reports • Nursing – Tour each other’s units • JCAHO Team – Three to four departments per month • Safety/ EOC Tours – All hospital areas twice per year

12. DAILYOPEN FOR BUSINESSTOURS

13. Open for Business Tours Yes or No? • Egress clear and free of tripping hazards? • Floors are clear of storage? • Doorstops not in use? • Exit signs illuminated? • Fire extinguishers located and accessible? • O2 tanks secured? • O2 emergency shutoff labeled? • Staff can articulate who turns off O2 in fire or emergency? • Staff can state what to do in the event of a fire? • Staff can state procedure for operating a fire extinguisher?

14. Open for Business Tours Yes or No? • Staff can state the location of the fire pull station? • Staff can articulate their role in a disaster? • Staff can state how to respond to a chemical spill? • Staff can identify room under negative pressure for patient isolation? • Staff can define and locate MSDS? • Staff can identify PI method? • Staff can articulate how to access P&P manuals? • Staff wearing Hospital ID? • Law enforcement have a Hospital red badge? • Code cart checked daily?

15. Open for Business Tours Yes or No? • Code cart intubation box available and accessible? • Medications secured – cart/room locked? • Emergency medication boxes within expiration date? • Medication has current dates? • Sample meds NOT present? • Med/Surg supplies are intact and within expiration date? • Syringes labeled with med and dose? • Open sterile solutions dated? • Medication refrigerator temperature log current? • Nutrition refrigerator temperature log current?

16. Open for Business Tours Yes or No? • No staff food in patient refrigerator? • Proper disinfectant and within expiration date? • Appropriate spill kit available (Lab & Chemo areas)? • Current PM stickers on equipment? • Storage does not exceed the 18” sprinkler head limit? • Under sink storage free from patient care and staff items? • Current reference books available? • Is patient privacy protected? • PPE is properly worn or removed following use? • Hand washing performed before or after patient or equipment contact?

17. QUESTIONS TO ASK STAFF DURING THESE TOURS TO TEST FOR GENERAL STAFF KNOWLEDGE

18. WHAT DO YOU DO IN THE EVENT OF A FIRE? • Remember RACE for fire safety: • Rescue/Remove person(s) from immediate fire scene/ room. • Alert/ Activate the nearest fire alarm pull station. Call out "CODE RED." Dial for help to explain details and give exact location. • Confine the area of the fire by closing ALL doors to rooms/areas • Extinguish a small fire by using a portable fire extinguisher or use it to escape a large fire. Evacuate horizontally; in patient buildings, to the next fire zone, or vertically by using the stairs, in all other buildings.

19. HOW DO YOU OPERATE A FIRE EXTINGUISHER? • Remember PASS for fire extinguisher use: • Pull the pin • Aim the nozzle at the base of the fire • Squeeze the handle • Sweep the stream back and forth at the base • WHERE IS THE LOCATION OF THE NEAREST FIRE ALARM? • As a general rule, pull stations are located at the entrance of stairwell doors. Locate the fire alarm pull stations in your work area.

20. HOW ARE YOUR SKILLS OR COMPETENCIES MAINTAINED OR UPDATED ON-THE-JOB? •  Examples may include: • Worksite specific orientation • Regularly scheduled and mandatory in-services • Tuition reimbursement program • Seminar/workshop attendance • Self learning tools, such as videos or articles • Participating on committees and/or limited purpose teams • Annual performance review • Vendor provided in-services for new equipment and/or products • Monthly unit/department meetings

21. WHAT IS THE MOST IMPORTANT MEASURE FOR REDUCING THE SPREAD OF GERMS IN THE HOSPITAL? • Hand hygiene is the MOST important measure. Hand sanitation must be performed before and after touching patients and after handling equipment used in their care. • Follow these steps: • Rub hands with Cal Stat, antiseptic waterless agent (as long as hands are not visibly soiled) or antimicrobial soap and water wash. • Visibly dirty hands must be washed with antimicrobial soap and water for 10 to 15 seconds. Using gloves does not replace hand sanitation. • Fingernail facts for direct patient care givers and food handlers: No artificial nails, overlays or extenders. Natural nails should not extend more than 1/4 inch over the pad.

22. WHAT DOES THE TERM STANDARD OR UNIVERSAL PRECAUTIONS MEAN? It means treating all patients’ blood, body fluids or specimens as if they were infected with a bloodborne pathogen – like Hepatitis B or C virus or HIV.

23. IS SMOKING ALLOWED ANY HOSPITAL BUILDING? No. WHERE CAN YOU FIND YOUR HOSPITAL DISASTER PLAN? All safety plans should be available. WHO IS THE HOSPITAL SAFETY OFFICER? Specific to your hospital. WHAT WOULD HAPPEN IN THE EVENT OF AN ELECTRICAL POWER FAILURE? All areas are equipped with emergency power to operate essential services: all exit lights, certain hall lights, all RED receptacles.

24. WHAT WOULD YOU DO IF THERE WERE A MEDICAL EQUIPMENT FAILURE? • Remove the equipment from service. • Tag the equipment according to policy. • Contact the Clinical Engineering Department. • Notify Risk Management if the failure resulted in serious patient harm, and sequester the equipment. • WHAT IS A MATERIAL SAFETY DATA SHEET (MSDS)? • A document that describes the properties of a product, any physical and health hazards associated with the product, precautions of safe handling, storage and spill control. The MSDS lists Personal Protective Equipment (PPE) that should be used in order to work with the material safely. Fire and first aid procedures are also listed on the MSDS.

25. WHERE ARE THE MSDS KEPT? MSDS are should be available in each department and all staff should know its exact location. WHAT IS A HAZARD VULNERABILITY ANALYSIS (HVA)? It is a formula used by the hospital to prioritize disaster planning. It uses the probability of an event occurring and the risk of harm to people and structures to identify the types of events we should be planning for.

26. WHAT ARE THE FOUR PHASES OF DISASTER RESPONSE? Phase A - An administrative alert that something could happen to impact the hospital. Phase B - An event that stresses the hospital but can be managed by the resources and staff available at the time. Phase C - An event that disrupts hospital operations and/or requires support from city resources. Phase D - An event that disrupts city operations and requires support from state and federal resources. WHAT IS MY ROLE IN A DISASTER? On-duty: During Phase B, C, or D report to your immediate supervisor. They will direct your next action. Off-duty: If you become aware that a large scale disaster has occurred, make sure your family is safe and then call contact the hospital for instructions on how to proceed. If the phone lines are down, listen to the radio for announcements. WHO IS AUTHORIZED TO SHUT OFF THE OXYGEN IN AN EMERGENCY? The charge nurse.

27. Review Tracer Reports • Managers are responsible for conducting tracers on a monthly basis in areas they are not responsible for. • Results are reported back and reviewed monthly at JCAHO Steering Committee. • Update Senior Management Monthly

28. Tracer Methodology

29. Form a Patient Safety Committee Charge: Maintain compliance with National Patient Safety Goals (NPSG) Co-Chairs: Likely same as JCAHO Steering Membership: Clinical Leadership with NSPG Oversight

30. Each NPSG has a team leader • Do 10 observations per week • Collect data • Track and trend • Report data 3rd week of month to Committee co-chairs • Review at next monthly meeting • Other NPSG Actions • NPSG posters • Hospital-wide NPSG screen savers • Intranet homepage coverage

31. Other Readiness Actions • Conduct regular Emergency Preparedness Drills • Ask for volunteers • Promote results good and bad • Lessons learned • Monthly Leadership Team auditorium updates • Weekly email questions and answers

32. HOW IS PATIENT SATISFACTION MEASURED? Boston Medical Center contracts with Press Ganey to conduct patient satisfaction surveys. Press Ganey surveys are conducted on inpatients and in some of the ambulatory settings. In addition, some services conduct their own patient satisfaction surveys. The results are shared at the monthly Leadership for Change meetings, as patient satisfaction is one of the performance indicators on Boston Medical Center's balanced scorecard.

33. WHAT IS THE APPROVED METHOD OF PERFORMANCE IMPROVEMENT AT BOSTON MEDICAL CENTER? • FOCUS-PDCA WHICH STANDS FOR: • Find an opportunity to improve • Organize a team that knows the process • Clarify the process • Understand the sources of variation • Select an improvement • Plan • Do • Check • Act

34. WHAT WOULD YOU DO IF YOU DISCOVERED A HAZARDOUS MATERIAL SPILL? • Immediately clear the area. Limit access to essential personnel only. • Call the Control Center. • Notify your supervisor. • Trained staff will clean the spill using PPE and spill kits. • Complete an Incident Report. • WHAT NUMBER DO YOU CALL FOR A SECURITY EMERGENCY, SUCH AS INFANT ABDUCTION OR A VIOLENT INCIDENT? • Call security. • WHAT DO YOU DO IF YOU FIND UNAUTHORIZED PERSONNEL OR PERSONS IN YOUR AREA? • Remain calm; do not panic. • If appropriate, ask the person(s) if you may help them. • If not, leave the area and contact security. • Remember distinguishing characteristics, eg. height, weight, race, and clothing.

35. WHAT DO YOU DO IF YOU RECEIVE A BOMB THREAT BY PHONE? • Remain calm. • Speak in a normal tone. • Listen for distinguishing characteristics of the caller's voice and background noise. • Call security. • Write down everything that you remember the caller saying and immediately give it to security. • WHAT SECURITY MEASURES ARE USED IN YOUR AREA? • I.D. Badges/ Card Access • Uniforms • Locks • Alarms • Crime Prevention Training • Cameras and monitors, emergency call boxes • WHAT IS A CODE PINK? • Infant/ Child Abduction

36. HOW ARE PATIENTS INFORMED ABOUT THEIR RIGHTS AND RESPONSIBILITIES? All patients should be aware of their Rights and Responsibilities. HOW ARE PATIENT COMPLAINTS HANDLED? Hospitals should have a standard protocol in place to handle patient complaints.

37. HOW DO PATIENTS RECEIVE INFORMATION ABOUT HEALTH CARE PROXY/ ADVANCE DIRECTIVES? Nursing staff, when completing the Multidisciplinary Admission History and Physical Assessment, will ask the patient if he/ she has a Proxy and document the patient's response. If the patient has executed a Proxy, but does not have a copy with him/ her, the nurse will document the content of the proxy, as stated by the patient. Patients and/ or their agent will be requested to bring a copy to be placed in the patient's medical record. Patients not having a Proxy will be offered an explanation. If the patient wishes to execute a Proxy during admission, Social Work is available to provide information and to assist with the completion of the Health Care Proxy. In the outpatient areas, any patient requesting a Health Care Proxy should be referred to the Patient Advocate.

38. Display case areas • Med Center News • Monthly JCAHO Chapter Reviews offered in auditorium setting • JCAHO Handbook

40. STEP 4 Testing for readiness/compliance.

41. Step 4: Test Testing for Readiness • JCAHO Tours • EOC/Safety Tours • Internal Mock Surveys • Twice/ Year • External Mock Surveys • One Full Survey/Year • One Focused Follow-up/ Year • Share Results with Entire Organization

42. AS SURVEY APPROACHES

43. WHAT CAN I DO TO PREPARE FOR THE SURVEY? • Become familiar with the National Patient Safety Goals (NPSG). • Become familiar with the standards that apply to your job and department. Attend training sessions. Read materials provided by your supervisor. • Ask your manager if you are unsure how to interpret the standards. • Know hospital’s mission statement. • Understand policies and procedures. These include fire, disaster, infection control, the right to know, bomb threat, code pink, incident and adverse drug event reporting.

44. TIPS FOR TALKING WITH SURVEYORS • Answer only the question you are asked! • Think carefully before answering the question. Take time to consider what the surveyor is looking for. Ask the surveyor to repeat or restate the question if you don't understand. • Be honest. If you don't know the answer, don't guess. Tell the surveyor how you can get the answer. In most cases you can ask your manager. Refer to policies and procedures, either departmental or administrative that will support your answers. • Give examples. For instance, if you are asked about performance improvement, mention an improvement activity that your unit/department was involved in. • Emphasize teamwork. Don't allow one person to do all the talking. If you have a role in the function being discussed, explain it.

45. HOW WERE YOU ORIENTED TO THE MEDICAL CENTER? • Each month, BMC holds several full day New Employee Orientation Programs. • Two half-day New Manager Orientation sessions are conducted quarterly. • HOW WERE YOU ORIENTED TO YOUR DEPARTMENT? • Worksite specific orientation is overseen by the manager and other knowledgeable co-workers. • Introduction to the Performance Management Process, which contains job description and position-specific standards. • Employees are given a preliminary performance review at conclusion of the orientation period. • Job specific competencies are detailed for employees. • WHAT EDUCATION OR TRAINING HAVE YOU RECEIVED IN THE LAST YEAR? •  Examples may include: • Safety and Infection Control • Workshops addressing Patient and Staff Satisfaction • Performance/ Quality Improvement Programs • Attendance at outside seminars and/or workshops • Enrollment at a local college for health-care related courses

46. WHO IS THE MOST IMPORTANT PERSON AT BOSTON MEDICAL CENTER? The PATIENT. WHAT IS BOSTON MEDICAL CENTER'S MISSION? Our mission is to provide consistently excellent and accessible health services to all in need of care, regardless of status or ability to pay. An integral part of our mission is to continually improve upon service quality to all our patients. The physicians, employees and volunteers at BMC are committed to providing the highest level of quality, patient-centered care - exceptional care without exception. WHAT IS BOSTON MEDICAL CENTER'S VISION? Our vision is to provide the highest quality, comprehensive care to all of the people of Boston and its surrounding communities, and to be particularly mindful to the needs of vulnerable populations, in an ethically and financially responsible manner.

47. WHEN DID YOU RECEIVE YOUR LAST PERFORMANCE REVIEW? • All non-union managers and staff receive a performance review annually in October as well as regular feedback throughout the year. • All other staff receive performance reviews annually either in April or October as well as regular feedback throughout the year. • WHAT ARE THE MANDATORY IN-SERVICES YOU RECEIVE EACH YEAR? • Fire Safety (RACE) • Infection Control • Disaster Preparedness • Hazardous Materials (Right to know) • Security • Utility Systems • Incident/Accident Reporting

48. STEP 5 Maintain readiness.

49. Step 5: Maintain Do it all over again • Each Week • Each Month • Etc.