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Nursing Administration is dedicated to the growth and development of BJHCHS and its Staff.

Below is a link to Posted JCAHO Information.

JCAHO Information
JCAHO Questions 1

JCAHO Information

Standard IM 6.20:	Records contain patient-specific information, as appropriate, to care, treatment, and services provided: Diagnostic/therapeutic procedures, tests and results Assessment: Including pain Diagnostic impressions Up to date medication list (every medication prescribed!!) Up to date problem list Allergies Advance Directives Informed Consents
Standard IM 6.40:	For patients receiving continuing ambulatory care services, the medical record contains a summary list of all diagnoses, procedures, drug allergies, and medications ( every medication prescribed ) initiated by the third visit.
Standard EC 2.10:	The organization identifies and manages its security risks. Who is the person(s) to contact concerning security activities? Do we identify patients, staff and other people entering the facilities? Do we control access to and egress from sensitive areas? What is the process to follow in the event of a security incident? How do we handle VIPS and media?
Standard HR 3.10:	Competence to perform job responsibilities is assessed, demonstrated, and maintained. How does your department measure competencies? If a determination is made that a person is unable or unwilling to improve, what action is taken? Are defined competencies reviewed during the orientation process?
	Patients with comparable needs receive the same standard of care, treatment, and services throughout the organization. Factors such as different individuals providing treatment do not intentionally negatively influence outcome. How do we as an organization ensure this occurs?
	The organization uses clinical practice guidelines to design or to improve processes that evaluate and treat specific diagnoses, conditions, or symptoms. What clinical practice guidelines have we developed? How have we utilized these to improve processes?
	The organization plans for managing medications. 1) The organization defines in writing that the following information is obtained to manage medications safely: age, sex, diagnosis, allergies, sensitivity, and current medications. 2) The organization defines in writing when the following are relevant to safe medication management: lab results, height, weight, pregnancy and lactation and any other additional information.
	Leaders establish priorities for performance improvement. Leaders give priority to high volume, high-risk, or problem-prone processes. Any staff member can identify process improvements by submitting them to the chair of the Performance Improvement. What are your departments performance improvement projects?

JCAHO Questions 1

What is the agency’s Mission statement?

Answer:

The mission of BJHCHS is to provide quality, accessible and comprehensive health care services to the South Carolina lowcountry community. How do you demonstrate your commitment to this mission in your work setting?

Who should have access to your log in and password?

Answer:

No one should have access to this information. It is a breech of security and could potentially lead to a HIPAA violation.

What is performance improvement?

The performance improvement program is the process in which we identify problem areas or processes that are not working well and develop a plan to improve or revise the process. Any staff member can participate in this process by identifying areas needing improvement and reporting the need to their department director. A PDSA cycle is done and the change should be piloted and reviewed to ensure the improvement has been accomplished. All departments involved in the process should be involved in the development of the plan. Who in your department attends the meetings?

What is the process for handling patient complaints?

You as the staff member can play an important part in handling complaints by being able to articulate the organizations policy and procedures correctly. Misinformation creates confusion and frustration. By calmly addressing the issue you might be able to defuse the situation. Should this not suffice the patient should be directed to the department director or given a patient complaint form which is sent to the Director of Nursing. All complaints are investigated.

Who is responsible for safety issues in the centers?

If you said the safety officers who are the DON and Director of Procurement you are perhaps 50% correct. Actually, you as a staff member are responsible for safety as well and should report any safety issues to your site coordinator who will in turn contact the appropriate safety officer. Wet floors, laboratory or supply cabinets unlocked, chemicals or solutions left where children might reach them are just some hazards you might see. In a life threatening safety issue you should dial 911 for assistance. Hazard surveillance surveys are done by the site coordinators and Nursing Administration to monitor hazards and safety issues.

What is a Code Red and what is your responsibility?

Code red is a fire or fire drill. These will be done on a quarterly basis initially. Each staff member has a specific duty during the process. What rooms to check, patient roosters, paging, money, etc? There should be one meeting place for all staff to go to during the drill or fire away from driveways and entrances. You are to know that area at each site and proceed there quickly. It is the agency policy to evacuate the building rather then attempting to fight the fire. Caustic or poisonous fumes can be omitted as a by product of the fire. Should you need to use a fire extinguisher remember PASS? Pull, Aim, Squeeze and Sweep. While reading this can you visualize where you nearest fire extinguishers are?

What is the one thing all of us can do to help with infection control? Good hand washing. When should you wash your hands? Real JCAHO Story. A surveyor was standing in the hall waiting to speak to a doctor. When the doctor came out of the exam room the surveyor asked the doctor if he washed his hands. The doctor answered of course. The doctor proceeded to leave while the surveyor went in the exam room. The sink was absolutely dry and no paper towel in the trash. OOPS