JCI标准与医院人力资源管理.ppt

This is a cardiac patient. Cardiology was a clinical service group identified as a high service area. The critical focus areas included rights and ethics, assessment and care, safety planning and engineering and medication use. Knowing that, as a surveyor, I know which standards are relevant and what survey activities will help in the systems analysis. This patient is currently an active patient on the cardiac care unit. To begin with, the charge nurse / clinical manager and the attending MD will participate in a thorough review of the record. This activity is designed to identify the actual “path” the patient took within the organization. In this case, the patient came in through the ED, went to the cardiac cath lab and then back to the unit. So the three units that will participate in the tracer are the cardiac care unit, the ED and the cath lab. After the thorough review, the survey process moves to the ED. There the nurse supervisor and other staff will be interviewed about such processes as their assessments, honoring patient rights such as advance directives, medication use. In addition, a tour of the unit will be conducted for safety issues, medication use etc. From the ED, the patient went to the cardiac cath lab. That’s where we will proceed. Again, the staff that are part of the lab will be part of the survey process. As a patient faces a procedure, it is important that orders are followed, the patient gives informed consent, etc. Those processes are reviewed in part during interviews and in part with the record. While in the lab, again the environment will be reviewed. After the cath lab, the patient went to the unit. That’s where we’ll end up. Post procedure, the processes which are important are how discharge planning is coordinated with educational needs, including pain management, medication and assessments. As you can see, the process is more real time that in past survey activities. In our previous example, the patient went from the ca