Regulatory Readiness

REGULATORY READINESS

"promoting excellence every day"

QUICK LINKS: Joint Commission Lab Survey \| Pocket Guides \| Tuesday Take Aways \| National Patient Safety Goals
LABORATORY SURVEY: The Joint Commission will conduct an unannounced survey of laboratory services between now and August 31, 2013. Surveyors will assess the care provided to patients in both inpatient and outpatient sites. A surveyor will arrive at your practice area accompanied by MGH leadership. The surveyor may review a patient’s record - observe care, tour the unit, and interview clinicians. Resources to help you prepare Click here
DPH INFECTION CONTROL SURVEY: The Department of Public Health (DPH) will conduct an Infection Control Survey anytime during 2013. Resources to help you prepare Click here

		Excellence Every Day Regulatory Readiness Resource Guides: Operations Associates Patient Care Associates Patient Care Services Licensed Staff Unit Service Associates


Tuesday Take Aways (MGH internal access only)	Communication tools* can when they are touched by contaminated hands (gloved or ungloved) and contribute to the spread of pathogens (e.g. MRSA, VRE, C. diff and resistant gram-negative bacteria). (4/30/2013) Joint Commission will be coming to MGH soon to evalutate Laboratory Services (4/23/2013) Strong Communication About Fall Risk Can Improve Patient Safety (4/10/2013) Tips for You Visit at MGH (3/26/2013) Focus on Falls: Overestimate Ability for Independence (3/19/2013) Effective Oral Care is important for all our patients (01/22/2013) More... Tuesday Take Away Special Edition: Important Nursing Practice Change! (10/23/12) Educating Patients about Infection Prevention (10/23/12) Storage of Clean Supplies in Patient Rooms (10/9/12) DPH Infection Control Survey 2012 (10/2/12) Surveyor Questions Related to Timeframes (7/10/12) Safe Practices with Patient Medication (INPATIENT) (7/3/12) Survey Readiness (6/26/12) Hazardous Medications (Inpatient) (6/19/12) Potential Surveyor Observation and Interview Questions (6/12/12) Medication Safety (6/5/12) Patient Education (updated 5/30/12) Potential Surveyor Observation and Interview Questions for National Patient Safety Goals (5/15/12) Nursing Plan of Care (Inpatient) (updated 5/30/12) Universal Protocol (5/1/12) Pain Assessment (4/24/12) Blood Transfusion Documentation (4/17/12) Performance Improvement: PDCA (4/10/12) Siderails as Restraint (4/3/12) Scope of Practice (3/27/12)

"Joint Commission Readiness" presentation (2/8/12) QUICK LINKS for JOINT COMMISSION READINESS: NPSG Resources \| Resource Guides \| Links \| Goal: 1 \| 2 \| 3 \| 7 \|15 \| Universal Protocol \| Additional Resources

National Patient Safety Goals (NPSGs) 2013 National Patient Safety Goals How National Patient Safety Goals are developed 2013 Comprehensive Accreditation Manual GOAL 1: Use at least two patient identifiers when providing care, treatment, and services Overview FAQs Quiz 10-Minute Mini-Tracer Selected MGH Policies and Procedures Related to NPS Goal 1 (in Trove; int**ernal access only): Clinical Policy and Procedure Manual Identity Verification Specimen Rejection Nursing Procedure Manual** 01. General Procedures - Blood Sampling: venipuncture 06-01-01- Transfusion Therapy 08-01-07-Medication Administration 08-01-07A- EMAPPS: Electronic Medication Administration Process for Patient Safety 14-06-01 -Procedure for Blood Glucose Testing Using Precision-Xceed Pro Monitor return to top of page
GOAL 2: Improve the effectiveness of communication among caregivers Overview FAQs Quiz 10-Minute Mini-Tracer Selected MGH Policies and Procedures Related to NPS Goal 2 (in Trove; internal access only): Clinical Policy and Procedure Manual Critical Tests and Critical Values return to top of page GOAL 3: Improve the safety of using medications Goal 3 has 3 standards related to safe medication management: labeling of medications, anticoagulation therapy, and medication reconciliation. NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Overview FAQs Quiz Related MGH Policy-Labeling in the OR: Mixture of Medications on the Sterile Field (internal access only) NPSG.03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Overview FAQs Quiz Related MGH Policy-Anticoagulation: Anticoagulants: Policy for Safe Use (Trove-internal access only) MGH Anticoagulation Guidelines (MESAC-internal access only) NPSG.03.06.01: Maintain and communicate accurate patient medication information. Overview FAQs Quiz Med Reconciliation Medication Reconciliation (Clinical Policy and Procedure Manual) (Trove-internal access only) Medication List Documentation and Management for Ambulatory Patients (Trove-internal access only) return to top of page Goal 7 has five standards related to preventing healthcare-associated infections. FOR STAFF: Infection Control: Dos and Don'ts PATIENT EDUCATION MATERIALS: Preventing Infections in the Hospital-How you can help stop the spread of germs Preventing Central Line Bloodstream Infections Preventing Wound Infections After Surgery NPSG.07.01.01: Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Overview NPSG.07.03.01: Implement evidence-based practices to prevent health-care associated infections due to multi-drug resistant organisms in acute care hospitals. Overview NPSG.07.04.01: Implement evidence-based practices to prevent central line-associated bloodstream infections Overview NPSG.07.05.01: Implement evidence-based practices to prevent surgical site infections Overview FAQs Quiz Policy (internal access only) NPSG.07.06.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). * Note: This NPSG is not applicable to pediatric populations. Research resulting in evidence-based practices was conducted with adults, and there is no consensus that these practices apply to children. Overview return to top of page NPSG 15.01.01 Identify patients at risk for suicide. Overview FAQs Quiz Policy (internal access only) Resources for Staff return to top of page Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery Universal Protocol Overview FAQs Quiz Policy (internal access only) UP.01.01.01: Conduct a preprocedure verification process. Overview UP.01.02.01: Mark the procedure site. Overview UP.01.03.01: A time-out is performed before the procedure. Overview return to top of page

	The Joint Commission and Patient Safety Open to the MGH community, an interactive session with Ann Scott Blouin, RN, PhD Executive Vice President, Division of Accreditation and Certification Operations, The Joint Commission Slide deck...click here Presentation video...click here