Temuan terbanyak JCI

The Numbers 97 full (initial/triennial) Hospital accreditation

surveys have been conducted using the 3rd

atio

nal

Edition manual. A total of 334 measurable elements scored

Not Met by at least one organization. No measureable element was scored more

than 8 times

Client name/ Presentation Name/ 12pt - 3

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athan 8 times. Top 20 Not Met standards/MEs: Cited in at least 4 to 8 surveys each

The Top 20

AOP 1 2 SQE 10 (ME 3)

Not Met findings come from 9 chapters:

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nal

AOP.1.2AOP.1.6 (ME 1)AOP.1.6 (ME 4)AOP.6.4 COP.3.8 ASC.3ASC.4

SQE.10 (ME 3)SQE.10 (ME 4) SQE.11 (ME 1)SQE.11 (ME 2)SQE.11 (ME 3) MMU.5.1MMU.6.1


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MMU.1GLD.1FMS.7.1

QPS.2.1 IPSG 3 IPSG 4

Copyright, Joint Commission International, 2011. May not be used without permission. 113

The most Frequently Cited Standard The most frequently cited standard was

it d 8 ti

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nal

cited 8 times.


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AOP.1.6

AOP.1.6 Patients are screened for t iti l t t d f ti l d

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nutritional status and functional needs and are referred for further assessment and treatment when necessary.

ME#4 Qualified individuals develop criteria to identify patients who require


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acriteria to identify patients who require further functional assessment.


Primary Issues Cited

No functional screening criteria developed

atio

nal

developed No functional screening policy

developed If the hospital does not have physical

therapy department and related f i l th i it i


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aprofessionals, the screening criteria are developed by those without the appropriate credentials

Additional Standards to Discuss

All of the standards are importantat

iona

l

We will discuss the following four standards to give you a better sense of why organizations miss critical standards.

In the appendix of this presentation we


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a In the appendix of this presentation, we list all of our top 20, and their primary problems.


ASC.3

ASC.3 Policies and procedures guide the care of patients undergoing moderate

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care of patients undergoing moderate and deep sedation.

ME#3 There is a pre-sedation assessment, according to organization

li t l t i k d


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apolicy, to evaluate risk and appropriateness of the sedation for the patient.


No pre-sedation policy is developedP d ti li i t i li ith th

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nal

Pre-sedation policy is not in line with the policy for pre-anesthesia assessment

Documented assessment does not meet policy requirements

Assessment does not really evaluate


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the risk of sedation Pre-sedation assessment is not

documented


FMS.7.1

FMS.7.1 The plan includes prevention, l d t ti i

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nal

early detection, suppression, abatement, and safe exit from the facility in response to fires and non-fire emergencies.

ME#5 The program includes the safe exit


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aME#5 The program includes the safe exit from the facility when fire and non-fire emergencies occur.


Fire doors are locked or blockedEmergency exits are not marked or lighted

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Emergency exits are not marked or lighted properly

Hall in patient units are clogged with equipment and supplies

Structural barriers of the building hamper exitI ti t id d h k l k th t


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a Inpatient corridor doors have key locks that could prevent occupant from exiting the room

Penetrations in smoke compartments


International Patient Safety Goals

IPSG #3 Improve the Safety of High-Alert Medications

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nal

Medications

ME #2 Concentrated Electrolytes are not present in patient care units unless clinically necessary and actions are t k t t i d t t


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ataken to prevent inadvertent administration in those areas where permitted by policy.


No policy is written at

iona

l

Concentrated solutions not secure when present and appropriately labeled

Unaware Magnesium Sulfate 50% is considered a concentrated electrolyteMany areas are identified as


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International Patient Safety Goals

IPSG #4 Ensure Correct-Site, Correct-P d C t P ti t S

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Procedure, Correct-Patient Surgery

ME #4 The organization uses a check list and time-out procedure just before starting a surgical procedure


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astarting a surgical procedure.


No documented evidence of using a checklist

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checklist Time-out is not documented Confusions about the difference

between the time-out and checklist Not used for all surgical procedures,


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e.g. dental & Cesarean section Resistance to using the protocol at all


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