PATTIE A. CLAY REGIONAL MEDICAL CENTER PRESENTS

1. PATTIE A. CLAY REGIONAL MEDICAL CENTERPRESENTS

2. JCAHO UPDATE 2000

3. COMMONLY ASKED JCAHO QUESTIONS AND ANSWERS

4. LEADERSHIP EMPLOYEE ALL EMPLOYEES

5. LEADERSHIP • Q.1What Changes Can We Expect at Our Next JCAHO Triennal Survey ?

6. LEADERSHIP • First, all employees could be involved in the survey since the JCAHO surveyors may choose to come back during off shifts to talk with additional staff members. Typically, this will happen when surveyors are getting mixed responses from staff or variations are identified.

7. LEADERSHIP • Second, our survey schedule will be changed to allow even more time to interact with staff members and inquire further on issues that may show weaknesses. • These survey activities have changed:

8. LEADERSHIP • Patient Care Setting Visits have been increased to 90 minutes each & a minimum of 2 open charts will be reviewed per unit.

9. LEADERSHIP • Information Management Interview has been combined with Medical Records Interview. More open chart reviews in patient care areas and less opportunities to select specific closed charts for review.

10. Patient Care Interview will concentrate on issues picked up during the survey and will also include: Anesthesia, Operative and Other Invasive Procedures Patient and Family Education Continuum of Care Medication Use and Nutrition Care Ethics and Patient Rights LEADERSHIP

11. LEADERSHIP Special Interview/Issue Resolution or Patient Unit Visit • includes time to allow surveyors to resolve any issues or spent visiting more areas that were not on the agenda. Surveyors may also use this time to review additional open charts.

12. LEADERSHIP • Performance Measurement and Improvement Interview combines the PI Overview, PI Team Presentation and PI Steering Committee Interview. Only 1 team will present (we select the team) and it will be limited to 15 minutes. The majority of time will be spent discussing ORYX data results and improvements being made as the result of this data

13. LEADERSHIP • Building Tourand Environment of Care Interviewhave both been increased by 30 minutes each. • Tour 3 hours, • Document Review 2 ½ hours.

14. LEADERSHIP • Q.2 Why are we having an inservice now when our survey isn’t until January 2002?

15. LEADERSHIP • TWO REASONS: • Mainly, the JCAHO is now sending updates nearly every quarter instead of annually. This requires us to be more timely with making changes and communicating these changes with all staff.

16. LEADERSHIP • Second, JCAHO is now conducting a higher number of RANDOM UNANNOUNCED SURVEYS!

17. LEADERSHIP • Q.3 What are the odds of Pattie A. Clay Regional Medical Center being selected for a random survey?

18. LEADERSHIP • A.3 We have more than 992,000 chances that we will have a Random Unannounced Survey than winning the Kentucky Lottery!! Here is how it works:

19. LEADERSHIP • A3 UP TO 10% OF HOSPITALS BETWEEN 9 - 30 MONTHS FROM THEIR TRIENNIAL SURVEY ARE RANDOMLY SELECTED FOR AN UNANNOUNCED SURVEY. • So PAC is eligible now through July 2001!

20. LEADERSHIP • GUARANTEED TOPICS INCLUDE: • PI: Aggregation/Analysis of Performance Data • TX: Medication Use • TX: Restraint Use • MS: Credentialing • EC: Plans Design & Review the Statement of Condition • HR: Competencies and Evaluations

21. LEADERSHIP • OTHER POTENTIAL TOPICS INCLUDE: • SENTINEL EVENTS • SERIOUS MEDICATION ERRORS • PATIENT TREATMENT ISSUES • REGULATORY ISSUES • STAFF-RELATED ISSUES • ISSUES OF PUBLIC CONCERN

22. LEADERSHIP • Q.4 What is the Future Vision for JCAHO for 5 or more Years Down the Road? • A.4 JCAHO is currently working on the following plans for the future: • INTEGRATION OF SELF-ASSESSMENT ACTIVITIES • DIVISION OF ON-SITE EVALUATION BROKEN DOWN INTO TWO (2) SEGMENTS IN AN 18-MONTH INTERVAL

23. LEADERSHIP • USE OF OUTCOME/PERFORMANCE DATA AS PROXIES FOR STANDARD COMPLIANCE • CREATION OF FULLY AUTOMATED ON-LINE INTERFACE • REDUCTION/ELIMINATION OF ADDITIONAL SURVEY FEES • HOLDING SURVEY FEES AT CURRENT LEVELS CURTAILING OTHER ACCREDITATION-RELATED COSTS

24. LEADERSHIP • INTEGRATING STANDARD EXPECTATIONS INTO DAILY OPERATIONS

25. LEADERSHIP • Q.5 If we are having a survey, what don’t you do when approached by a JCAHO Surveyor?

26. LEADERSHIP • A.5 Don’t attempt to hide, ignore, avoid or run from them, unless of course you are involved in a patient care activity which would prohibit you from immediately responding!

27. LEADERSHIP • In other words, go about your work and be certain to greet the surveyor (good morning/afternoon).Based on past experience, the employees that “dodge” the surveyors are exactly the employeesthat they want to talk to . So, don’t be afraid and remain calm and friendly! RELAX ..TAKE A DEEP BREATH!!

28. LEADERSHIP • To date, no hospitals have ever reported any employee injuries during a JCAHO survey! Just remember they tooare human beings and it is not as painful as you may think to tell them what you know. Just in case you do panic, it will still be okay if you don’t know the answer, then tell them so.

29. LEADERSHIP • Q.6 What is a mission statement? • A.6 Any of the following answers are good: • It is the purpose of an organization • it stands for what we believe in/it tells us where we want to be in the future/it explains who we are and what we do.

30. LEADERSHIP • Q.7 What does your hospital mission statement mean to you? • A.7 Any of the following answers are good but you probably have a much better answer yourself!!! BE PREPARED TO ANSWER IN YOUR OWN WORDS!

31. LEADERSHIP • We serve a culturally diverse population..which means we treat patients from all walks of life, therefore, we must respect their differences and meet their special needs. (Examples: 1) migrant workers who are non-English speaking, 2) elderly patients who have difficulty hearing, seeing , and may be frightened, alone, confused etc. 3) young first time mothers who may need more education and emotional support , etc.

32. LEADERSHIP • Our mission statement tells me how we define quality .which is providing friendly service to our customers by doing the right thing, the right way, the first time. I help deliver that quality by . (give a simple example of what you do that is good! Brag on yourself!!

33. GIVE YOURSELF A BLUE RIBBON

34. LEADERSHIP MISSION STATEMENT • We work hard to be clinically effective and economically efficient..which means we can’t be everything to everybody .what we do, we must do well and affordable .

35. LEADERSHIP • Our mission statement tells me our vision of “serving the healthcare needs of people in our region as we have become a regional healthcare facility.

36. LEADERSHIP • Our mission statement tells me that we value patients rights involve our patients and families in decision making regarding their care and respect their ability to make choices including end of life decisions.. We must inform them of the risks, benefits, alternatives & respect their decisions

37. LEADERSHIP • Q.8 What is your definition of quality? • A.8 We define quality as providing friendly service to our customers by doing the right thing, the right way the first time.

38. LEADERSHIP • Q.9 Who are your customers? • A.9 Everybody! Patients, Families, Visitors, Physicians, Co-workers within my department and other departments

39. LEADERSHIP • Q.10 What is a “hospital wide patient plan of care” mean to you? • A.10 It is a detailed document that describes the services offered in each department—(scope of services), description of department, location, hours of operation, staffing plans, etc.

40. This plan is a policy # ADM-010-040 throughout the hospital, and is used by management to plan for improvements and/or changes in the services we provide. It is useful in making good patient care decisions which is helpful in strategically planning for our future. Be sure you know what is included under your department section of this plan.

41. LEADERSHIP • Q.11 How do you make certain the same level of care is provided to your patients throughout the hospital?

42. LEADERSHIP • A.11 Our staff and Management develop collaborative policies and procedures which allows various departments to work together to maintain consistency in processes done in different locations of the hospital. Ongoing communication and interaction with other departments is key to our success.

43. LEADERSHIP • (You need to be prepared for giving an example of how something done is your department that is also done by others is performed with consistency could be as simple as our hospitalwidehandwashing techniques to minimize the spread of infections, transporting DNR informationwith all patients as they visit different departments/units, etc.)

44. ENVIRONMENT OF CARE LIFE SAFETY

45. EOC LIFE SAFETY • Q.1 Who is responsible for safety at your hospital? • A.1 All employees!! Safety is an important part of every employee’s job at Pattie A. Clay Regional Medical Center.

46. EOC LIFE SAFETY • Q.2 What does “Environment of Care” mean? • A.2 “EOC” is another word for managing our safety program.

47. EOC LIFE SAFETY • Q.3 What is included in your safety program at our hospital? • A.3 Our safety program consists of seven(7) areas which is monitored/measured at all times including:

48. EOC LIFE SAFETY • 1) General Safety: Visitor/Patient Incidents Employee Accidents Common Space/Grounds Safety

49. 2) Life Safety::Fire 3) Security: Theft, violence, etc. Workplace Violence 4) Emergency Preparedness: Disaster Tornado Bomb Threat, etc. 5) Hazardous Materials and Waste: Right To Know MSDS Chemicals, Radioactives, Gas Explosives, and Wastes Mercury EOC LIFE SAFETY

50. EOC LIFE SAFETY • 6) Medical Equipment: Patient Care • 7) Utilities Management: Electric Phones Water Sewage , etc.