A JCAHO Progress Note
BWH has been granted full accreditation from the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO). This prestigious honor comes as the result
of the JCAHO acceptance of our corrective action plans, which were implemented
in response to issues identified during the February 2004 survey. BWH is required
to address and correct six identified issues, four of which require measurements
to demonstrate our progress.
Of these six issues, four directly relate to nursing care:
Initial Patient Assessment: BWH needs to provide a comprehensive assessment of
patients as they enter the hospital. This is the first step in building a complete
and continuous record from admission-to-discharge.
Abbreviations: JCAHO prohibits certain abbreviations in patient records to
prevent medical errors, particularly those related to the medication process.
Advanced Care Directive/Health Care Proxy: Patients who have an Advance Care
Directive or Health Care Proxy must have a signed copy in their current chart
in order for care providers to know their wishes.
Two Patient Identifiers: It is required that staff use two methods of identifying
patients prior to medication and blood administration and/or obtaining blood/laboratory
specimen samples. Neither of the identifiers can be the patient’s room number.
Other JCAHO areas requiring improvement include patient assessment before anesthesia
induction and procedures, and obtaining a signed informed consent prior to performing
procedures that require it. BWH staff is currently conducting mandatory random
audits of patients’ medical records to measure the success of the corrective
action plans. These audits commenced in May and will continue through September.
The results of these audits are tallied monthly, the totals of which will be submitted
to JCAHO in October. A rate of 90 percent compliance or higher is required to
avoid the risk of a change in the BWH accreditation status from Fully Accredited
to Provisionally Accredited.
According to Cathy Breen, RN, program manager for Nursing Quality Management,
“We’d like to encourage nursing staff to maintain the energy and commitment
that was so evident during the February survey. It’s important for all of
us to remain vigilant on patient safety issues and to continually assess our level
of compliance with JCAHO standards today,” she said. “Improving our
compliance scores will require everyone working together.”
The 2005 JCAHO Patient Safety Goals have been released with a new focus on
assessing patients for fall risks as well as medication reconciliation. Effective
January 2006, all JCAHO hospital surveys will be unannounced.