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JCAHO survey to include new criteria  

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t’s nearly that time again: beginning December 8, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will spend five days conducting Children’s accreditation survey.

During the visit, the commission will evaluate the performance of hospital systems, patient care processes and quality improvement initiatives. The survey will include extensive documentation reviews, clinical site visits and in-depth interviews with senior administration, staff, employees, patients and families.

In addition to the survey process many staff are familiar with, this year JCAHO will evaluate how well Children’s has embedded the National Patient Safety Goals into everyday practice. Surveyors are likely to focus on multidisciplinary team members in every clinical department.

They will also obtain “real time” views of patient care by reviewing records during their visits to different clinical care areas. Clinicians in every discipline should be aware of these changes and focus on improving documentation practices wherever necessary.

JCAHO is an independent, not-for-profit organization that evaluates the quality and safety of healthcare institutions and grants accreditation. If you have questions about the survey, e-mail lynne.grady@tch.harvard.edu.

Patient Safety Goals With key actions for achieving them  Improve accuracy of patient identification  Use two patient identifiers and TIME OUT prior to invasive procedures  Improve communication among caregivers  READ BACK/FEEDBACK on every verbal and telephone order  Standardize acceptable abbreviations used in the hospital  Improve safety of high-alert medications  Remove all concentrated electrolytes form patient care areas  Standardize and limit the number of drug concentrations in hospital  Eliminate wrong-site, wrong-patient and wrong-procedure surgery  Use pre-op verification process to confirm documents  Implement a process to mark surgical site and involve the patient and family  Improve the safety of using infusion pumps  Ensure free flow protection on all general use and PCA intravenous infusion pumps  Improve effectiveness of clinical alarm systems  Implement regular preventative maintenance and testing of alarm systems  Assure appropriate settings and they are sufficiently audible  Reduce the risk of healthcare-acquired infections  Comply with CDC hand hygiene guidelines  Manage as sentinel events all identified cases of unanticipated death or permanent loss of function associated with a healthcare-acquired infection

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