Some Important Tips for JCI Survey

Common Questions & Explanation

Very ImportantTo know

• Their achievement is critical to full compliance with the JCI standards.

• Any failing goals is consider a failing in JCI ACCREDITATION.

1-What is the process of identifying patient? & when it must be used ?

Patient is identified (Hospital ID band).

• before any treatment, collection of samples, blood transfusion, drug administration, diagnostic test or procedure is conducted

• Patient’s complete Name, Hospital ID Number, National ID card/Iqama

• Patient’s Full Name: Refers to the patient’s name to the Third Level.

For infant/ child:

• Identification should be carried out by two hospital staff using identification information available in the Medical Records

Important:

• In the event identification band is lost

• it must be reported as ‘Incident Report’ to prevent using the lost band in infant/child abduction.

IPSG.1 Identify Patient’s Safety:

• 2-What is process for Telephone/Verbal Orders and when receiving Critical Values Result?

• 1-Verbal Order: • limited to urgent situations where immediate

written/ electronic communication is not feasible.

Verbal/ Telephone Order: will not be accepted for:

• Physical restraints, Starting Patient Controlled Analgesia (PCA),

• Starting Narcotic/ Scheduled medications, Initiating TPN therapy

• Category of care (Code status), Withdrawal of life support, Chemotherapy.

Critical Test Reporting (Laboratory & Radiology):

• ‘Write Down, Read-Back, Confirm/Verify’

• For Telephone Orders, responsible physicians requires to sign order within (24 ) h.

• For Verbal Orders, physicians require signing order after situation is over Or before physician leave the area.

• Handovers: See hospital wide Handover Form, used for communicating critical content between health care providers during handovers of patient care.

• IPSG.2 Improve Effective Communication:

• 3-What is your process to ensure safe identification, storage, preparation and dispensing of High Alert Medications (HAM)?

• The hospital has a list of all high-alert medications, including look-alike / sound- alike medications that is developed from hospital-specific data.

• Look-alike and Sound-Alike (LASA) medications are recommended to have Tall Man letters over the medication storage

• Examples: • • EPINEPHrine and EPHEDrine -

VinBLASTIN” and “VinCRISTINE.

• All high alert medication shall be stored in a secured cabinets and clearly labelled.

• Concentrated electrolytes are stored ONLY in areas that requires it with appropriate labelling.

• - Storage bins for HAM based on its strengths shall be segregated.

• It is the responsibility of MRP to prescribe medications within the approved formulary that includes orders and prescribing HAM.

• Verbal orders for HAM are only allowed during Emergency or Life threatening situation

• HAM orders must be double checked during preparation & before administration.

•

• IPSG.3 Improve the Safety of High-Alert Medications (HAM):

• 4-When does the Time-out conducted?

• TEAM TIME OUT- applied to some procedures /first skin incision performed for paediatric patients:

All activities should be STOPPED and all members of the

surgical/procedural team must fully participate in the TIME-OUT

• Confirms all members are present and attentive.• Addresses the following standard information:• -Correct patient identity• -Correct type of procedure to be performed• -Correct procedure site has been marked (if applicable) • -Availability of correct equipment for the procedure.• Correct and appropriate documents and diagnostic images

are available.• Any attending staff can identifies anticipated critical

events

• IPSG.4 Ensure Correct-Site, Correct Procedure, Correct Patient Surgery:

• What is the process in your department to reduce HAI’s?

• -You must be familiar with (MCWP 1-1-9415-02-003 Hand-Hygiene)

• - You must be familiar with (5-Moments of Hand Hygiene)

• Before touching a patient. • Before a procedure.• After a procedure or body fluids exposure risk.• After touching a patient.• After touching a patient surroundings

• - You may be asked to demonstrate how to do:• 1- Hand Rub Procedure.• 2- Hand Wash and Hand Disinfection

Procedure

• • IPSG.5 Reduce the Risk of Health Care-Associated Infections:

6-When is fall risk assessment/reassessment conducted ?

• ASSESSMENT: • Upon patient admission

in the unit.

REASSESSMENT:

– Transfer of patient from one unit to another within the facility

– Any changes in patients status/condition

– Following a fall

• -Patient initial fall risk nursing assessment performed Within (3) hours of admission using

• the ‘Humpty Dumpty Fall Scale’ and

• re-assessment daily or with any changes.

• - Score 6-11 is: Low Risk –

• Activate low risk prevention protocol by nursing.

• Score 12 and above is: High Risk –

• Activate high risk prevention protocol by nursing

For Paediatric in-patients ages 3 months to 14 y/o,

• Identified as high risk of fall:

• Will be fitted with yellow ID printed with “FALL RISK” and a Humpty Dumpty to be placed outside the patient’s active medical file.

- For Neonates and/or Infants ages 0 to 3 months, Identified as high risk of fall:

• Must have a • Humpty Dumpty sticker

to be placed outside the patient’s active medical file and a

• Humpty Dumpty poster placed at the bedside.

For Out-patient & ED:

• Nursing Screening for fall risk, and if parameters are positive will receive a full risk assessment.

• Use of assistive device i.e. Gait unstable, Poor balance and Focuses on apparent need.

• Patient Re-assessment at each visit.

After a Fall What is Physician’s Role?:

• 1- Assess level of injury and treat any resulting problem.

• • 2- Initiate diagnostic& treatment

interventions for contributing intrinsic & extrinsic causes

• 3- Document post-fall assessment and treatment.

• 4-Find out probable cause of fall, such as history, physical factors, medications, and laboratory values.

• 5-Refer patient to appropriate services if needed.

• Important:

• All events of patients fall: An ‘Incident Report’ must be completed.

IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls:

International Patient Safety Goals (IPSG)

• “Very ImportantTo know”

• Their achievement is critical to full compliance with the JCI standards.

• Any failing goals is consider a failing in JCI ACCREDITATION.