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 firstname.lastname@example.org.
Patient Safety Goals
With key actions for achieving them
- Improve accuracy of patient
- Use two patient identifiers and TIME OUT prior
to invasive procedures
- Improve communication among
- READ BACK/FEEDBACK on every verbal and telephone
- Standardize acceptable abbreviations used in
- Improve safety of high-alert
- Remove all concentrated electrolytes form patient
- Standardize and limit the number of drug concentrations
- 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
- 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
- Reduce the risk of healthcare-acquired
- 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