Please note: This is a Department Analysis Project for JACHO Review in Healthcare Management setting. The Hospital for this review is Northwestern Hospital in Chicago, Illinois. There should be an Overview of the hospital history including location, Standards, Policy, Procedures and Protocols as required by JCAHO. See below. Only provide what you can obtain on the website. ۈ €„¢ What are the standards and procedures for the following? Orientation, Training and Education Rationale for Standard HR.2.10 (Human Resources) 1. The hospital€â€žÂ¢s mission goals 2. Hospital wide policies and procedures (including safety and infection control) and relevant unit, setting, or program-specific policies and procedures 3. Specific job duties and responsibilities and unit, setting or program-specific job duties and responsibilities related to safety and infection control 4. Cultural diversity and sensitivity 5. Persons are educated about the rights of patients and ethical aspects of care, treatment, and services and the process to address ethical issues. Rationale for Standard LD. 3.60 (Leadership) 1. The leaders ensure processes are in place for communicating relevant information throughout the hospital in a timely manner. 2. Effective communication occurs in the hospital, among the hospital€â€žÂ¢s programs, among related organizations, with outside organizations, and with patients and families, as appropriate. 3. The leaders communicate the hospital€â€žÂ¢s mission and appropriate policies, plans, and goals to all staff. Rationale for IM 3.1 (Information Management) Minimum data sets, data definitions, codes, classifications, and terminology are standardized whenever possible. Examples of Implementation for IM.3.1 through IM.3.2 1. Standardized coding and reporting systems include: €Ú¢ Public health reporting requirements; €Ú¢ Coding systems for discharge diagnoses for billing; €Ú¢ Reporting to state and federal health planning and analysis agencies; €Ú¢ Internal case mix analysis; and €Ú¢ Data for performance improvement activities. €Ú¢ Some examples of standardized nursing nomenclatures include €Ú¢ North American Nursing Diagnoses Association List of Approved Diagnoses; €Ú¢ Nursing Intervention Classification Quality control examples include. €Ú¢ Defining criteria for data capture and data input or recording; €Ú¢ Defining statistically appropriate sampling procedures; €Ú¢ Reviewing medical records for completeness, accuracy, and timeliness; €Ú¢ Reviewing and addressing the qualifications of persons who are responsible for performing the quality measurement. €Ú¢ Using single data entry for multiple uses €Ú¢ Applying a define process for checking data €Ú¢ The organization develops and enforces data policies, standards, and procedures to define projects and work requirements and efficiently collect and effectively use data accordingly to the plan. €Ú¢ Organization wide policies and procedures €Ú¢ Department policies and procedures €Ú¢ Data element definitions, abbreviation lists, codes and data dictionary €Ú¢ Interviews with staff Rationale for PI 1.10 (Performance Improvement) The hospital collects data to monitor performance. Data help determine performance improvement priorities. 1. The hospital collects data for priorities identified by leaders 2. The hospital considers collecting data in the following areas €Ú¢ Staff opinions and needs €Ú¢ Staff perceptions of risks to patients and suggestions for improving patient safety €Ú¢ Staff willingness to report unanticipated adverse events 3. The hospital collects data on the perceptions of care, treatment, and services of patients including the following €Ú¢ Their specific needs and expectations €Ú¢ How well the hospital meets these needs and expectation €Ú¢ How the hospital can improve patient safety €Ú¢ The effectiveness of pain management, when applicable The hospital collects data that measure the performance of each of the following potentially high-risk processes, when provided 4. Medication management 5. Blood and blood product use 6. Restraint use 7. Seclusion use 8. Behavior management and treatment 9. Operative and other invasive procedures 10. Resuscitation and its outcomes Relevant information developed from the following activities is integrated into performance improvement initiatives. This occurs in a way consistent with any hospital policies or procedures intended to preserve any confidentiality or privilege of information established by applicable law 11. Risk management 12. Utilization management 13. Quality control 14. Infection control surveillance and reporting 15. Research as applicable 16. Autopsies, when performed Rationale for MM.2.10 (Medication Management) 1. Members of the medical and LIPs, appropriate health care professionals, and staff involved in ordering dispensing, administering, and/or monitoring effects of medications develop written criteria for determining what medications are available for dispensing or administration 2. At a minimum, the criteria include the indication for use, effectiveness, risks (including propensity for medication error, abuse potential, and sentinel events), and costs. 3. A list of medications for dispensing or administration (including strength and dosage) is maintained and readily available. 4. Processes and mechanism are established to monitor patient responses to a newly added medication before the medication is made available for dispensing or administration within the hospital 5. Medications designated as available for dispensing or administrations are reviewed at lease annually based on emerging safety and efficacy information. 6. The hospital has processes to approve and procure medications that are not on the hospital€â€žÂ¢s medication list. 7. The hospital has processes to address medication shortages and outages, including the following: €Ú¢ Communicating with appropriate prescribers and staff €Ú¢ Developing approved substitution protocols €Ú¢ Educating appropriate LIPs, appropriate health care professional, and staff about these protocols €Ú¢ Obtaining medications in the event of a disaster. Rationale for PC.1.10 (Patient Care) The hospital accepts for care, treatment, and services only those patients whose identified care treatment, and service needs it can meet. 1. The hospital has a defined written process that includes the following: €Ú¢ The information to be gathered to determine eligibility for entrance into the hospital €Ú¢ The patient populations accepted or not accepted by the hospital (for example programs designed to treat adults that do not treat young h d children) €Ú¢ The criteria to determine eligibility for entry into the system €Ú¢ The procedures for accepting referrals €Ú¢ The hospital accepts patients for care, treatment, and services accordingly to established processes. Rationale for PE.1.6 (Patient Assessment) To provide for continuity of care, follow-up planning begins when the patient enters the setting. Patients follow-up needs are assessed when indicate. The organization uses a process for assessing patients€â€žÂ¢ needs for follow-up care. 1. Organizations that utilize the €æ€œSOAP€Ú medical charting approach (subjective data, objective data, assessment and plan) identify the follow-up care needed and incorporate this information ito the discharge plan. 2. Policies that define when follow-up care is performed may include specific time frames for continuing care of individual with diabetes and patients with other chronic diagnoses. €Ú¢ Interviews with staff €Ú¢ Review of patient records (for example, admission for, H&P, progress notes, charts and graphics) Rationale for EC.1.8 (Environment of Care) A mechanism needs to be in place determine that staff maintaining medical equipment and performing tests are trained in and competent to perform all procedures. Staff also needs to understand the potential for cross-contamination of equipment. For example, a biomedical technician performing preventive maintenance on suction equipment in the operating room utilities appropriate infection control procedure, including hand washing and decontamination of the area after work is completed. Or, when testing new equipment before placing it in use, all internal and external parts that were €æ€œworked on €æ€œare cleaned before re-assembly and use in patient care. €Ú¢ Management plans for the issue(s) addressed in the standard €Ú¢ Performance monitoring for the issue(s) addressed in the standard €Ú¢ Emergency procedures for the issue(s) addressed in the standard €Ú¢ Staff interviews Rationale for TX.3.1 (Medication Use) The organization identifies in appropriate selection of medication available for prescribing or ordering 1. Staff of an ambulatory clinic conducted an intensive asse3ssment of the use of drug samples as the result of a news story about a mother who was given a sample for her child that was part of a lot recalled by the manufacturer because its dosage was intended for adults. 2. Policies, procedures, or guidelines address the €Ú¢ Appropriateness of the drugs in the formulary for the patients and diseases treated by a facility €Ú¢ Mechanisms for adding drugs to or deleting drugs from the formulary €Ú¢ Procedures for obtaining medications not listed in the fomulary €Ú¢ Safety, efficiency, cost-effectiveness, and use of pharmaceutical (that is, generic) equivalents €Ú¢ Person(s) who by law may prescribe medications €Ú¢ Drug reactions and interactions that may occur; and €Ú¢ Use of sample drugs, including proper safeguards Rationale for IC.1.10 (Infection Control) €Ú¢ Policy and procedure on Hand Hygiene/Washing €Ú¢ Policy of Protective Equipment €Ú¢ Respiratory Procedure and Policy on VAP