Joint Commission: Requirements for Improvement

Accreditation Decision: Preliminary Denial of Accreditation
Decision Effective Date: February 17, 2007
This organization is not in full compliance with all applicable standards.

Requirements for Improvement:

Home Care
-An ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients is defined and implemented.
-The director named on the CLIA certificate establishes policies and procedures that define the context in which waived test results are used in patient care, treatment, and services.
-Measure, assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

Hospital
-The leaders measure and assess the effectiveness of the performance improvement and safety improvement activities.
-Undesirable patterns or trends in performance are analyzed.
-An ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients is defined and implemented.
-Newly constructed and existing environments are designed and maintained to comply with the Life Safety Code®.
-The hospital maintains fire-safety equipment and building features.
-The hospital develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Code®.
-Medical equipment is maintained, tested, and inspected.
-The hospital maintains, tests, and inspects its medical gas and vacuum systems.
-Medications are properly and safely stored.
-Medication orders are written clearly and transcribed accurately.
-The hospital evaluates its medication management system.
-Initial assessments are performed as defined by the hospital.
-The hospital has a complete and accurate medical record for patients assessed, cared for, treated, or served.
-The hospital collects data to monitor its performance.
-Designated qualified staff accept and transcribe verbal or telephone orders from authorized individuals.
-The leaders develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital.
-Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
-Measure, assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
-Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
-Mark the operative site as described in the Universal Protocol
-The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege

http://www.qualitycheck.org/qualityreport.aspx?hcoid=4718