Patient safety and quality care

As previously discussed in our last newsletter, we are now in our Joint Commission (TJC) survey window for our 2019 Triennial Accreditation Survey. Surveyors have been arriving as early as 10 weeks in advance and have surveyed Eastern Idaho Medical Center and Alaska Regional Hospital, both in our Division. Our survey deadline is October 30, but we expect to be surveyed as early as July.

While Life Safety and Environment of Care findings remain at the top of the list for most recently cited, there continue to be opportunities you can affect in positive ways:

1. Complete and timely history and physical: Recent gaps have included lack of medical history and medication lists.
2. Complete Time Out performed for all invasive procedures: Time Outs are not relegated to operating rooms and should be performed before all invasive procedures in all areas of the facility.
3. Legible and complete orders and signatures when using paper forms: Illegible handwriting can lead to clinical errors putting patients at risk.
4. Hand hygiene when entering and leaving patient rooms.
5. Complete documentation of informed consent when applicable: Identified gaps include documentation of risks and benefits, opportunity for clarification/questions with family and appropriate interpreter available and documented as needed.
6. Procedural Sedation: Follow established policy regarding sedation including pre-procedural assessments, post-procedural assessments and appropriate discharge instructions.

Along with our clinical and ancillary staff, you are our eyes and ears, and we rely on you to drive our efforts toward elevating the quality of care we provide our patients. You can help set the tone for continued survey readiness in your areas and facility-wide.

We thank you for your commitment to providing our community with high-quality, compassionate care. If you have questions regarding our TJC accreditation processes or would like clarification regarding regulatory processes and CMS/TJC Conditions of Participation, please reach out to Renee DeHaas (*56505) at renee.dehaas@hcahealthcare.com.