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Methodist Hospital

Joint Commission Tracer Compliance Checklist

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Associated Event   
* Area/Unit Surveyed
* Surveyor
* Date
* Staff Surveyed
  Was staff surveyed wearing identification badge above their waist? YES     NO     N/A    
  If Patient diabetic was care-plan on the chart? YES     NO     N/A    
  Interdisciplinary Plan of Care was in the medical record demonstrating multidisciplinary care planning? YES     NO     N/A    
  The medical record showed evidence of involving the patient and family in the health care. (e.g. documentation of involvement in site marking, discussion of options other than restraints, falls interventions, discussion of options for pain management, dis YES     NO     N/A    
  Informed consent was obtained for operative or invasive procedures? YES     NO     N/A    
  Advance directive was in medical record, unless patient declined to do one. Can find existence of advance directive if present. Verbalized process. YES     NO     N/A    
  Evidence of follow-up on Advance Directive if patient wanted one. Verbalized process. YES     NO     N/A    
  All entries are signed, dated, and timed. YES     NO     N/A    
  Unacceptable abbreviations were not found in the medical record. Is there a list of unacceptable abbreviations available? YES     NO     N/A    
  Patient Assessment was completed within eight hours. YES     NO     N/A    
  If patient was assessed as at-risk for suicide, a referral was made to the attending physician. YES     NO     N/A    
  Pain was reassessed 15-30 minutes after a parenteral dose or 1 hour after an oral dose or non-pharmacologic intervention. YES     NO     N/A    
  Pain reassessment included pain relief, side effect, change in function and patient satisfaction on the daily bedside flow sheet. Pain assessment and scale documented. YES     NO     N/A    
  Each PRN medication order has a documented indication. YES     NO     N/A    
  Patient/family teaching is recorded in the patient teaching record. YES     NO     N/A    
  Staff gave an example of a procedure done in their area requiring informed consent and universal protocol. Staff described Universal Protocol? YES     NO     N/A    
  Staff described where the preoperative verification, site marking, and time out are recorded for operative and invasive procedures performed in their area. YES     NO     N/A    
  Staff explained our Hand-Off Communication Method and included the SBAR process? YES     NO     N/A    
  Staff described where they would find physician privilege to practice information. (OCOM Medical Staff Department). YES     NO     N/A    
  Staff described the steps taken if a piece of equipment fails causing serious injury or death.1. YES     NO     N/A    
  Staff described hand hygiene guidelines? YES     NO     N/A    
  Staff gave examples of near misses or occurrences that should be reported in Med Marx and the process for reporting. (Medication error, adverse drug reaction, equipment problems, falls, errors related to procedure/treatment/test, complication of procedure YES     NO     N/A    
  Staff described the steps that must be taken in order for a patient to self-administer medications:1. YES     NO     N/A    
  Staff described what is done when a patient takes the first dose of a new medication. (Pharmacist reviews order unless urgent, whenever possible the purpose of each new medication and any potential clinically significant adverse reactions or other concern YES     NO     N/A    
  Staff described the steps prior to the administration of high-alert medications. (Double checks are required by two licensed practitioners prior to administration). The double check is documented directly on the patient medication administration record by YES     NO     N/A    
  Staff described how narcotics are wasted, the process for documenting the waste, and how discrepancies are resolved. YES     NO     N/A    
  Staff described how patients could report concerns about safety. House Supervisor - Manager, Self Governance Team) YES     NO     N/A    
  Staff identified what they do when taking a verbal order or critical test result. (Write it down, read it back, receive confirmation) YES     NO     N/A    
  Staff named 3 fall risk factors. (Confusion/disorientation, depression, altered elimination, dizziness/vertigo, male gender, prescribed anti-epileptic, prescribed benzodiazepine, get up and go test). Staff described process in place to reduce patient fall YES     NO     N/A    
  Staff described the amount of time allowed for reporting a critical test result to a licensed caregiver who can act on the results. (30 minutes) Is there a process in place to measure, collect data, and analyze results for timeliness of reporting critical YES     NO     N/A    
  Staff described how medications are reconciled while the patient is under the care of the organization, specifically at admission, during transfer, and at discharge. Is this communication documented? YES     NO     N/A    
  Staff described a performance improvement project currently on their unit. YES     NO     N/A    
  Staff described process in place to respond to unexpected worsening in patient;s condition. YES     NO     N/A    
  Staff described root cause analysis (RCA) and gives an example. YES     NO     N/A    
  Staff described process in place to prevent infections due to multi drug resistance organisms. YES     NO     N/A    
  Staff described process in place to prevent central line associated blood stream infections. YES     NO     N/A    
  Staff described process in place to prevent surgical site infections YES     NO     N/A    
  Staff described the organization's anticoagulantion program. YES     NO     N/A    
  Staff described how to report unresolved concerns regarding patient safety or quality care. YES     NO     N/A    
  No expired medications or supplies are found. YES     NO     N/A    
  Look-alike/sound alike medications are segregated. Is there a list of SALAD available? YES     NO     N/A    
  Multi-dose vials are dated. YES     NO     N/A    
  Patient refrigerator temperature control logs are up-to-date and when the temperature is out of range, corrective action is documented on log or refrigerator alarm is turned on. YES     NO     N/A    
  Any document with Protected Health Information (PHI) is turned, covered, or filed away from public view. YES     NO     N/A    
  Medical records are not left unattended in areas open to the public (e.g. records are placed behind nurses/clinical stations or in rooms that are closed). YES     NO     N/A    
  Patient Hand-Off form is used when a patient's care is transferred temporarily or permanently. SBAR process observed during Hand-Off. YES     NO     N/A    
  No food & drink in patient care areas or areas where there is a potential for occupational exposure to blood borne pathogens (e.g. nursing stations, clinics, labs, radiology). YES     NO     N/A    
  Electrical patient care equipment has current year's inspection label. If not, contact Biomed. YES     NO     N/A    
  Isolation signs clearly visible on doors. YES     NO     N/A    
  Needles secured - locked or under direct supervision at all times. YES     NO     N/A    
  Exit doors not blocked open or obstructed by furniture. YES     NO     N/A    
  Medications, including over-the-counter products and plain IV solutions, are secure (locked or under direct supervision at all times and medication room carts locked. YES     NO     N/A    
  Prescription pads are secure. YES     NO     N/A    
  No undated or outdated food in inpatient patient food refrigerators (nothing should be older than 72 hours). YES     NO     N/A    
  Staff washes their hands before and after patient contact. YES     NO     N/A    
  All reagents, controls, strips, etc… are properly stored: proper temperature, dated when opened if required, non expired. YES     NO     N/A    
NPSG's
Goal 1 - Accuracy of Pt Identification
  NPSG.01.01.01 - 2 identifiers when providing care, treatment and services YES     NO     N/A    
  NPSG.01.03.01 - Eliminate transfusion errors related to pt misidentification YES     NO     N/A    
Goal 2 - Improve effectiveness of communication among caregivers
  NPSG.02.03.01 - Report critical results of tests and diagnostic procedures on a timely basis YES     NO     N/A    
Goal 3 - Improve the safety of using medications
  NPSG.03.04.01 - Label all meds, med containers & other solutions on & off the sterile field in periop & other procedural settings. YES     NO     N/A    
  NPSG.03.05.01 -Reduce the likelihood of pt harm associated with the use of anticoagulant therapy YES     NO     N/A    
Goal 7 - Reduce the risk of health care associated infections
  NPSG.07.01.01 - Comply with hand hygiene guidelines YES     NO     N/A    
  NPSG.07.03.01 - Implement evidence based practices to prevent HAI's due to MDRO's YES     NO     N/A    
  NPSG.07.04.01 - Implement evidence based practices to prevent central line associated bloodstream infections YES     NO     N/A    
  NPSG.07.05.01 - Implement evidence based practices for preventing surgical site infections YES     NO     N/A    
Goal 8 - Medication Reconciliation
  NPSG.08.01.01 - A process exists for comparing current meds with those ordered for the pt YES     NO     N/A    
  NPSG.08.02.01 - When pt referred or transferred to another hospital, the complete & reconciled list of meds is communicated to the next provider of service & the communication is documented. YES     NO     N/A    
  NPSG.08.03.01 - When pt leaves the hospital, a complete & reconciled list of meds is provided directly to the pt & as needed, the family, & the list is explained YES     NO     N/A    
  NPSG.08.04.01 - In settings where meds are used minimally, or prescribed for a short duration, modified reconciliation processes are performed. YES     NO     N/A    
Goal 15 - The hospital identifies safety risks inherent in its pt population
  NPSG.15.01.01 - Identify pts at risk for suicide YES     NO     N/A    
Universal Protocol - applies to all surgical & nonsurgical invasive procedures
  UP.01.01.01 - Conduct a preprocedure verification process YES     NO     N/A    
  UP.01.02.01 - Mark the procedure site YES     NO     N/A    
  UP.01.03.01 - A time out is performed YES     NO     N/A    
Core Measures
  Pneumonia YES     NO     N/A    
  CHF YES     NO     N/A    
  AMI YES     NO     N/A    
  Surgical Care YES     NO     N/A    
  OP Chest Pain and AMI YES     NO     N/A    
  OP Surgical Care YES     NO     N/A    
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