JCIA Accreditation Participation Requirements (APR):

JCIA Accreditation Participation Requirements (APR):

“A TRANSPARENT practice”: Mandates which are rational for requirements evaluation methods and consequences of non-compliance accreditation process and maintaining an award.

T Timely submission of data and information
R Reports (within 15 days) of any changes in hospital profile or information
A Accurate and complete information through all phases of accreditation
N Notifies the public of concerns about patient safety and care
S Submits accurate representation of accreditation status
P Participates in Library of Measures
A Allow JCIs board and staff to observe the onsite survey
R Reporting from individual concerned about the hospital without retaliatory action
E Endow with patient care in an environment that poses no risk
N Notify review of original authenticated results and reports
T Translation and interpretation service arrangements during audit days

 

TRANSPARENT-JCIA Accreditation Participation Requirements (APR)

TRANSPARENT-JCIA Accreditation Participation Requirements (APR)

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INTERNATIONAL PATIENT SAFETY GOAL (IPSG): Identify Patients Correctly

CHAPTER ONE: 

INTERNATIONAL PATIENT SAFETY GOAL (IPSG):  

IPSG  

Identify Patients Correctly

Two approved identifiers (inpatient & OPD) Use third identifier if patients with same name, look-alike, sound-alike + name alert flagging.   

DEFINITIONS

  • Active Patient Identification — the process of identifying a competent adult patient by asking his/ her to tell the staff his/ her full name while staff ensures it matches the information on his/ her ID band and medical record file, as appropriate.
  • “Patient identifiers” are those names, numbers, etc., whose purpose is to uniquely identify one particular patient and distinguish him/her from all other eligible medical recipients.
  • Electronic ID Band — Patient ID Band is being printed electronically using thermal printers. It is a new system implemented in the hospital as part of initial phase of implementation for the integration of hospital information through electronic system.
  • Vulnerable Patients — patients who are unable to communicate due to temporary communication impairments (such as those who are unconscious, heavily medicated, on ventilators, or are in intensive care or recovery) or cannot communicate because of language barriers and an interpreter is not readily available, age (such as infants), cognitive impairments (such as dementia or behavioral disorders), or medical condition (such as coma).

Patient Identification is required in the following (but not limited to):

  • Upon admission/ first contact — patient identification shall commence upon the first contact with administrative staff members like reception for check-up/ follow-up (for outpatient) and ADT (admission, discharge & transfer) staff during opening file for admission (for inpatients). This step is crucial because all subsequent identification episodes will be based on the information captured in the first contact.
    • Before providing treatments (such as administering medications, blood, or blood products, serving restricted diet trays; or providing radiation therapy).
    • Performing procedures (such as insertion of an intravenous line or hemodialysis).
    • Before any diagnostic procedures (such as taking blood and other specimens for clinical testing, or performing a cardiac catheterization or diagnostic radiology procedure).
    • During transfer, discharge and confirmation of death
  • For labor cases, upon admission aside from taking the female patient’s I.D., it is a must to take copy of the male companion (father/husband/brother) I.D. must be kept in the patient’s file.
  • For emergency cases, if the patient’s ID is not available, copy of the ID from patient’s next of kin must be kept in the patient file.

There are two (2) approved identifiers per setting for:

  1. INPATIENT setting:
    1. Patient full name (three names for Arabic patients)
    2. Patient Medical Record number
  2. OUTPATIENT setting:
    1. Patient full name (three names for Arabic patients)
    2. National ID and/ or Iqama number
  • Additional identifier for inpatient must be used in rare cases when two (2) patient identifiers are the same for more than one person, ID and of the patient must be used as third identifier.
  • Room number, bed number and sex (except for newborns) are never used as patient identifiers.
  • In cases when patients are having the same name and look or sound very much alike, a NAME ALERT process must be carried out to decrease the risk of error.
  • ID Band (Electronic or Manual)
    All admitted patients will have an ID band Outpatients do not wear ID bands except for outpatient setting in which patients are receiving treatments/ medications and procedures like:

    • Patients in Emergency Room (ER).
    • Patients having procedures with procedural moderate sedation / analgesia.
    • Patients on haemodialysis
    • Patients in Assisted Reproduction Unit
    • Patients in Nuclear Medicine
    • Patients in Radiology & Imaging Department where prolonged stay is anticipated [e.g. Intravenous Pyelogram (IVP), MRI with contrast, CT-Scan with contrast, Fine
    • Needle Aspiration (FNA)]
    • Newborn Circumcision
  • Application of ID Band will be as follows:
    • Patient wrist or the easiest accessible limb
    • In case when patient is undergoing surgery and the existing ID band needs to be removed then OR staff will generate temporary ID band and attach to the next available limb.
  • Exemptions in ID Band application:
    • If application of ID band as a “bracelet” is impossible (i.e. if patient is limbless, or is extremely agitated and harms him or herself by trying to remove the bracelet, if the patient has burned extremities, or is an extremely premature newborn, etc.).
    • Visibly attach ID band to the patient’s bed / crib
    • This application is to be noted in the patient’s Nurses Progress Notes.
  • If the ID band is fading, missing, or contains information that is incorrect, the test, treatment, medication, procedure, etc. will not be performed until the information is corrected and the patient is accurately identified.
  • Vulnerable Patients:
    • Vulnerable patients with ID band – verification of patient identification must be done by having the Registered Nurse check the patient’s name and medical record number on the ID band against the information from the medical record file.
    • Vulnerable patients without ID band – verification of patient identification must be done by confirming patient ID against the medical record and contact next of kin to confirm patient identification.
  • For unknown and unresponsive patients (such as Trauma Patient in ER) identification is made by ER Staff, assigned a temporary name and an ER number or medical record number until the patient true identity is established.
  • Labeling of medical record with correct patient identification. Check addressograph labels to ensure the patient information is correct before using them on medical records, test requests, prescriptions, etc.
  • Label specimens using electronically printed sticker labels and apply it in the room or in the immediate vicinity of the patient and never in another location. Check carefully that the ID information matches the patient and the clinician’s order. Always finish labeling one patient’s specimen before collecting/ labeling another set of specimens.
  • Discharge of Patient, the Registered Nurse will be the one removing the ID band before patient is released from the unit.
  • In the event of patient death, the ID band shall remain on the patient.

A new ID Band shall be generated and re-applied to the following situation:

  • when ID band is fading
  • when ID band is missing
  • when ID band is having incorrect information
  • when ID band was removed for clinical procedures like cannulation
  • If the ID Band is fading, missing, or contains information that is incorrect, the test, treatment, medication, procedure, etc. will not be performed until the information is corrected and the patient is accurately identified.
  • For inpatients, a new Electronic ID band shall be requested from the ADT Office by the Registered Nurse with patient’s medical record.
  • Two (2) Registered Nurses shall be involved in changing patient ID band after patient verification.
  • Documentation of change of ID band shall be reflected in the Nurses Progress Notes.
  • For unknown and unresponsive patients (such as Trauma Patient in ER) identification is made by ER Staff, assigned a temporary name and an ER number or medical record number until the patient true identity is established.
  • Labeling of medical record with correct patient identification. Check addressograph labels to ensure the patient information is correct before using them on medical records, test requests, prescriptions, etc.
  • Label specimens using electronically printed sticker labels and apply it in the room or in the immediate vicinity of the patient and never in another location. Check carefully that the ID information matches the patient and the clinician’s order. Always finish labeling one patient’s specimen before collecting/ labeling another set of specimens.
  • Discharge of Patient, the Registered Nurse will be the one removing the ID band before patient is released from the unit.
  • In the event of patient death, the ID band shall remain on the patient.

NAME ALERT

To decrease the risk of error when patients have same name and look or sound very much alike:

  1. Patient should not routinely be placed in the same room.

Exception: Husband, wife, mothers, sisters, father / son, mother /daughter — requesting the same room may the accommodated.

  1. At the time of admission, prepared “Name Alert” label, shall be placed on the patients:
    1. Chart front
    2. Unit dose ( MAR )
    3. Nursing notes
    4. Inform all personnel or duty and at change on shifts of name similarity.a

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About Healthcare Practice in Saudi Arabia

About Practice in Saudi Arabia

saudi photoFor the last few decades, the Kingdom of Saudi Arabia has been welcoming hundreds of thousands of healthcare practitioners from all over the globe, regardless of their country of origin or religion. As any other civilized country, it has its own regulations along with deeply-rooted social customs that are largely based on Islam as a cornerstone. Obviously, the Kingdom has been adopting the Islamic Sharia as the main regulations and legislation reference, as clearly stated in the Basic System, which is more or less the constitution of the country. The healthcare system is not an exception. Therefore, it is reasonable to expect many of the issues that healthcare practitioners face in their practice will be seen, analysed and resolved from the Islamic perspectives. This book has to be seen within the efforts of the SCFHS designed to help not only the non-Arabic-speaking practitioners to have a better ethical guidance, but also for the non-Muslim Arabic-speaking practitioners to have a better understanding of the basics of the Islamic approach to such issues.

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LEVELS of the Culture of Safety Program

LEVELS of the Culture of Safety Program

LEVELS of the Culture of Safety Program

Hospital Leaders acknowledge that the healthcare environment is a high-risk environment and seek to align vision/ mission, staff competency, and fiscal and human resources from the boardroom to the frontline.

The role of senior leadership is a key element to designing, fostering, and nurturing a culture of safety. Engaged senior leaders are critical to an organization’s successful development of a culture of safety. Engaged leaders drive the culture by designing strategy and building structure that guide safety processes and outcomes identified administrative leadership as one of the most significant facilitators for establishing and promoting a culture of safety.

Creating a culture of safety must begin with the Chief Executive Officer (CEO), but it must permeate throughout every level of the healthcare system. Leadership’s commitment and education on safety culture is key to an organization’s move toward a safety culture. Leaders require basic insight into safety problems and need rationales for focusing on patient safety. They need to be educated on the science of safety and the power of data.

The benefit of this approach is that the process is up-front and transparent to the staff, which helps achieve trust and accountability.

A Just Culture, “Just Culture Not Blame, Also not Carefree”:

  • Recognizes that individual practitioners should not be held accountable for system failings over which they have no control (8o% of medical error are system-driven).
  • Recognizes many errors represent predictable interactions between human operators and the systems in which they work; and recognizes that competent professionals make mistakes.
  • Acknowledges that even competent professionals will develop unhealthy norms (shortcuts, “routine rule violations”).
  • Has zero tolerance for reckless behavior.
Establishment of just culture

Establishment of just culture

Establishment of a just culture is the first vital step in engineering a safer culture. While employees will be disinclined to report errors and near misses in a wholly punitive culture, a totally blame-free culture is equally undesirable given that some unsafe acts warrant retribution. Importantly, leadership strikes a balance between the systems approach that emphasizes organizational learning, and the need to retain personal accountability and discipline. In the end, hospital leaders must hold individuals accountable for the safety environment while also providing them with the security of knowing they will not be blamed for system failures beyond their control. In short, formation of a just culture requires the establishment of a zero tolerance policy for reckless conduct, counterbalanced by a widespread confidence that unintended unsafe acts will generally go unpunished (Please see Code of Ethics for Healthcare Practitioners, Ed. 2014).

  • System (reporting)

 Cultivation of a reporting culture is the next critical step in creating a safer organizational culture. Once a just culture is in place, the workforce should feel safer reporting errors and near misses. However, important psychological and organizational barriers to reporting are likely to remain. For example, people are naturally reluctant to confess mistakes and risk blame or the possibility that reports will be kept on permanent record and held against them in the future.

Also, workers may be skeptical that reporting errors, particularly those that reveal system weaknesses, will actually spur managerial actions that lead to meaningful change. As a result, staff may come to believe that event reporting requires more time, effort, and risk than it is worth.

Hospital leaders continuously support potential strategies to overcome these barriers and encourage a reporting culture that include maintaining the confidentially of those who report adverse events; granting partial indemnity against disciplinary procedure; separating the report collection and analysis functions; and delivering timely feedback to the entire organization.

  • Teamwork

Is one of the critical elements in safety culture. Teamwork is treating patients with increasingly complex disease processes and with increasingly complex treatments and technologies requiring stronger efforts toward applications of teamwork and collaboration among caregivers to achieve a system-wide culture of patient safety.

Teamwork means a spirit of collegiality, collaboration, and cooperation exists among leaders, staff, and independent practitioners. Relationships are open, safe, respectful, and flexible.

  • Training

Even with an effective incident and near miss reporting system in place, Hospitals also works to develop a learning culture to truly reap the benefits of institutional memory that stem from the capacity to uncover and track safety risks. In order to accomplish this learning culture, leaders encourage the manifestation of a systems approach to understanding human error, and can lead to systemic reforms rather than local repairs. As a general concept of the implementation of a safe culture, Hospitals believes that safety variances that occur within healthcare practices provide learning opportunities, challenging and transforming the basic assumptions that brought about the unsafe act.

 

  • Patient Involvement

Patient care is centered on the patient and family. The patient is not only an active participant in his own care; but also acts as a liaison between the hospital and the community. Hospitals embrace the patient and family as the sole reason for the hospital’s existence. It promises to value the patient by providing a healing environment during the hospitalization and also to promote health and well-being as a continuum of care.

It is the responsibility of the hospital leadership to commit to patient-centeredness as a core value. Leaders should challenge the medical staff and all employees to make every effort toward focusing on the patient and offering the patient an exemplary experience marked by caring and compassion. Hospitals allow and empower patients to be participatory in their care decisions.

Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.

Hospitalized patients are routinely surveyed about their satisfaction with the care they received, empowering them to speak up having found that patients often report errors that were not detected through traditional mechanisms such as chart review.

Patient stories can be used to put a “face” on system failures leading to potentially serious adverse events. Stories enhance the richness of description and create an atmosphere where discussion can lead to safety action.

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Just Culture

Just Culture

Just Culture

The benefit of this approach is that the process is up-front and transparent to the staff, which helps achieve trust and accountability.

A Just Culture, “Just Culture Not Blame, Also not Carefree”:

  • Recognizes that individual practitioners should not be held accountable for system failings over which they have no control (8o% of medical error are system-driven).
  • Recognizes many errors represent predictable interactions between human operators and the systems in which they work; and recognizes that competent professionals make mistakes.
  • Acknowledges that even competent professionals will develop unhealthy norms (shortcuts, “routine rule violations”).
  • Has zero tolerance for reckless behavior.

 

Establishment of just culture

Establishment of just culture

Establishment of a just culture is the first vital step in engineering a safer culture. While employees will be disinclined to report errors and near misses in a wholly punitive culture, a totally blame-free culture is equally undesirable given that some unsafe acts warrant retribution. Importantly, leadership strikes a balance between the systems approach that emphasizes organizational learning, and the need to retain personal accountability and discipline. In the end, hospital leaders must hold individuals accountable for the safety environment while also providing them with the security of knowing they will not be blamed for system failures beyond their control. In short, formation of a just culture requires the establishment of a zero tolerance policy for reckless conduct, counterbalanced by a widespread confidence that unintended unsafe acts will generally go unpunished (Please see Code of Ethics for Healthcare Practitioners, Ed. 2014).

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Leadership Commitment

Leadership Commitment

Leadership Commitment

Hospital Leaders acknowledge that the healthcare environment is a high-risk environment and seek to align vision/ mission, staff competency, and fiscal and human resources from the boardroom to the frontline.

The role of senior leadership is a key element to designing, fostering, and nurturing a culture of safety. Engaged senior leaders are critical to an organization’s successful development of a culture of safety. Engaged leaders drive the culture by designing strategy and building structure that guide safety processes and outcomes identified administrative leadership as one of the most significant facilitators for establishing and promoting a culture of safety.

Creating a culture of safety must begin with the Chief Executive Officer (CEO), but it must permeate throughout every level of the healthcare system. Leadership’s commitment and education on safety culture is key to an organization’s move toward a safety culture. Leaders require basic insight into safety problems and need rationales for focusing on patient safety. They need to be educated on the science of safety and the power of data.

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DELEGATION OF SAFETY CULTURE PROGRAM

DELEGATION OF SAFETY CULTURE PROGRAM

ASPECTS OF SAFETY Fish Diagram

ASPECTS OF SAFETY Fish Diagram

KEY FUNCTIONS AND ROLES

  1. Chief Executive Officer and Hospital Executive Leadership
  • Establishes and supports the hospital’s culture of safety program that promotes accountability and transparency.
  • Develops and documents code of conduct and identifies and corrects behaviors that are unacceptable.
  • Provides education and information (such as literature and advisories) relevant to the hospital’s culture of safety to all staff.
  • Defines how issues related to a culture of safety within the hospital are identified and managed.
  • Provides resources to promote and support the culture of safety within the hospital.
  • Provides a simple, accesible and confidential system for reporting issues relevant to a culture of safety in the hospital.
  • Ensures that all reports related to the hospital’s culture of safety are investigated in a timely manner.
  • Identifies systems issues that lead healthcare providers to engage in unsafe behaviors.
  • Uses measures to evaluate and monitor the safety culture within the hospital and implement improvements identified from measurement and evaluation.
  • Implements a process to prevent retribution against individuals who report issues related to the culture of safety.

Quality Management Department

  1. Supports the hospital’s culture of safety program that promotes accountability and transparency.
  2. Coordinates with Safety team, Infection Control team, Pharmacy team, Nursing team and other concerned according to the requirement.
  3. Receives, investigates and acts upon issues or incidents related to the hospital’s culture of safety.
  4. Ensures that all reports related to the hospital’s culture of safety are investigated in a timely manner.
  5. Provides education and information relevant to the hospital’s culture of safety to all staff.
  6. Manages and provide summary reports to leaders on a quarterly basis.
  7. Encourages staffs to report issues relevant to a culture of safety in the hospital.
  8. Identifies systems issues that lead healthcare providers to engage in unsafe behaviors.
  9. Uses measures to evaluate and monitor the safety culture within the hospital and implement improvements identified from measurement and evaluation.

Heads of Department/ Service:

As a commitment to the culture of safety program, each head of the department/ service is responsible for:

  1. Implementing the hospital’s culture of safety program within the department.
  2. Identifies, documents and corrects behaviors that are unacceptable within the department.
  3. Provides education and information relevant to the department’s culture of safety in coordination with QM.
  4. Encourages staffs to report issues relevant to a culture of safety in the hospital.
  5. Helps evaluate and monitor the safety culture within the department or service and implement improvements identified from measurement and evaluation.

Departmental QI Officers

  1. Assists in the implementation of departmental and hospital-wide culture of safety program
  2. Collaborates with the Head of the Department/ Service and the Quality Management Department in monitoring, reporting and communicating issues relevant to a culture of safety in the department.

Hospital Staff Members

  1. Holds a proactive and positive attitude towards reporting culture of safety occurrences.
  2. Initiates and reports culture of safety related incidents using the hospital’s OVR system.

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PATIENT SAFETY & HARM REDUCTION COLLABORATIVE

PATIENT SAFETY & HARM REDUCTION COLLABORATIVE

To maintain and improve patient safety, departments/ units partnered/ collaborated with other departments/ units to be able to formulate measures/ indicators that focuses in patient safety and harm reduction. Some of the above measures/ indicators have been around for years, modified/ revised according to new requirements while others are newly created. Hospital leaders fully supported for these significant improvements to be carried out for patient care outcomes which includes (but not limited to):

  1. 100% compliance with patient identification
  2. 95% compliance with the use of SBAR in Nursing
  3. Consistent Hand Hygiene compliance of 9o%
  4. 0% of patients on ventilator contracted VAP
  5. 0% incidents of Surgical Site Infection (551)
  6. Central line bloodstream infection rate sustained at o%
  7. 100% compliance with completion of WHO Surgical Safety Checklist in OR setting (SIGN IN, TIME OUT, SIGN OUT) and TIME OUT in Non-OR setting
  8. 0% incident of Medication Error
  9. Zero incident on Patient Fall
  10. > 95% compliance with antibiotic prophylaxis given within 6o minutes before surgical incision
  11. 95% compliance with VTE assessment on admission (including prescribing prophylaxis)
  12. Reduction of Hospital Acquired Pressure Ulcer (HAPU) to 03%
  13. 95% compliance in Pain assessment and documentation
PATIENT SAFETY & HARM REDUCTION COLLABORATIVE

PATIENT SAFETY & HARM REDUCTION COLLABORATIVE

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What is JCI Accreditation?

What is JCI Accreditation?

Joint Commission International Accreditation is a voluntary process in which an entity separate and distinct from the health care organization which assesses the health care organization to determine if it meets a set of requirement (standards) designed to provide a visible commitment by an organization to improve the safety and quality of care which is optimal and achievable. It is an effective quality evaluation and management tool for ensuring a safe care environment which helps continuous improvement process to reduce risk to patient and staff.


Who are JCI?

Joint Commission International is a U.S. based not for profit accreditation body which sets and designs standards and processes to create a culture of ethics, safety and quality within an organization that strive to continually improve patient care processes and results.


Benefits of JCI Joint Commission International teaches and leads us to:

  1. Improve patient trust by improving patient safety, quality and care.
  2. Provide a safe and efficient work environment that contributes to staff satisfaction
  3. Listen to patients and their families, respect their rights, and involve them in the care process as partners; and
  4. Helps establish collaborative leadership that sets priority for and continuous leadership for quality and patient safety at all levels.

What is Tracer Methodology?

Tracer methodology is an evaluation method in which a surveyor selects a patient and uses that individual’s record as a roadmap to assess and evaluate an organization’s compliance with selected standards and the organization’s system for providing care and services.

 

What is the role of the staff in the survey/during a tracer?

As surveyors move around the hospital, they will ask to speak with the staff members who have been involved in the tracer patient’s care, treatment and services. Assume they will want to talk with you, so have confidence in yourself—you provide awesome care, so let them see it! Remember that you are prepared to answer their questions.

 

Consider the following recommendations:

  • Be certain to greet the surveyor (good morning/ good afternoon) with a smile, introduce yourself, including your title, and accompany the surveyor to your area and/ or to you department head/ supervisor/ in-charge
  • Be confident and remain calm, don’t attempt to hide, ignore or run from them.
  • Answer their questions directly (keep your answers short and sweet) and ask the surveyor to repeat or rephrase the question if you don’t understand it.
  • Be polite and smile—do not let the questions make you feel defensive or angry.
  • Be honest—if you do not know the answer, do not make one up; tell them you don’t know but you will ask your senior staff or your colleague who knows the answer.
  • Be specific, provide examples for an answer and refer to policies or procedures whenever possible
  • Be enthusiastic about what you do.

 YOUR MISSION

To serve the healthcare needs of the region by giving comprehensive care.

To treat and to prevent illness.

To provide advanced procedures & modern technology combined with the traditions of caring & compassion.

 

Our CORE VALUES as healthcare providers

RESPECT: We interact professionally with others and affirm that each person has special value, unique talents and varied gifts. We offer open mindedness, recognition a rid appreciation to the perspectives and experiences that others bring to the table and are willing to share.

TEAMWORK: We work together to achieve our goals. We make effective teams through respectful interpersonal communication dynamics building a supportive teamwork environment and camaraderie with our co-workers.

INTEGRITY: We do the right thing. We Act ethically arid responsibly in all services we do.

EXCELLENCE: We do the best thing. The best service, best experience and best practices to provide the highest quality care for our patients and their families.

COMPASSION: We are advocates for a compassionate and just society through our actions and our words. Be empathic by listening, reflecting and accepting people and where they are in life, conscientiously care for our environment, be with those most vulnerable and recognize that not only patients, but also their families and our co-workers need help from time to time.


JCI Standards (5th Edition)

Accreditation Participation Requirements (APR): 12 Chapters Total Number: 16

  • Patient Centered Chapters: 8
  • Organization Management Chapters: 6
  • Academic Medical Center Hospital Chapters: 2

Standards: Total Number: 304

Standards are set around the important functions; they are common to all healthcare organizations.

Intent statement: Easy explanation of the standards

Measurable Elements: 1218 (total number), measurable elements are those requirements of standards which are reviewed and assigned a score during survey.

Survey: Assesses the hospitals compliance on JCI standards

Chapters Details

  • Accreditation Participation Requirements
    Accreditation Participation Requirements (APR)-Introductory
  • The Patient Centered Standards are:
    • International Patient Safety Goals (IPSG)
    • Access to Care and Continuity of Care (ACC)
    • Patient and Family Rights (PFR)
    • Assessment of Patients (AOP)
    • Care of Patients (COP)
    • Anesthesia and Surgical Care (ASC)
    • Medication Management and Use (MMU)
    • Patient and Family Education (PFE)
  • The Organization Management Standards are:
    • Quality Improvement and Patient Safety (QPS)
    • Prevention and Control of Infections (PCI)
    • Governance, Leadership, and Direction (GLD)
    • Facility Management and Safety (FMS)
    • Staff Qualifications and Education (SQE)
    • Management of Information (M01)
  • The Academic Medical Center Hospital Standards are:
    • Medical Professional Education (MPE)
    • Human Subjects Research Programs (HRP)

JCI addresses the following issues very intensively:

  1. International Patient Safety Goals
  2. Patient & Family Education
  3. Patient & Family Rights & Responsibilities
  4. Pain Management
  5. Quality Indicators & Monitoring
  6. Hand Hygiene & Prevention and Control of Infection
  7. Fire Safety and Emergency Codes
  8. Removal of Barriers to Care
  9. Patient Identifiers
  10. Care of High Risk Patients (Vulnerable patients)
  11. Restraint Order
  12. Rights of Drug administration
  13. Discharge Planning & Components of Discharge Summary
  14. Time Out process
  15. Biomedical Waste Disposal
  16. Personal Protective Equipments (PPE)
  17. HAZMAT, Lab, Radiation, Facility Safety
  18. DNR (Do Not Resuscitate)
  19. End of Life Care
  20. Hospital Mandatory Trainings

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Safety & Loss Prevention Officer – JOB DESCRIPTION

  • Responsible for :

The implementation of Environment Of Care Programs and activities, and shall assist the Senior Safety Officer. Responsible for gathering Safety information as well as relevant applicable laws and regulations in order to identify safety risk to patients, visitors, and personnel. He will provide quarterly reports to the Safety & Loss Prevention Manager on Environment of Care Six (6) Planning areas: Safety & Security Management; – Hazardous Materials & Waste Management; – Emergency Management; – Fire/Life Safety Management; – Medical Equipment Management; – and the Utility System Management issues including actions and recommendations of the FMS Committee.

Responsible for the day-to-day work activity scheduling of Safety Technician & Fire Watch

He shall report to the Senior Safety Officer and accountable to the Group Safety & Loss Prevention Manager and the Deputy Chairman, have a direct line of communication to the all Department Heads and Department Safety Officer (DSO).

The Safety & Loss Prevention Officer is subject to being on-call 24 hours/7 days /week to respond to emergencies.

  • Liaises with:                             Heads of the Departments/DSO/Supervisors, FMS
    Committee Chairman/Other Committee
  • Duties and Responsibilities:
  1. The Safety Officer manages a hazard surveillance program that collects and analyzes data for the Facility Management & Safety (FMS) Committee.
  2. Serves as a member of the Facility Management & Safety (FMS) Committee. Monitors Facility Management & Safety Committee recommendations and actions to measure effectiveness and reports to Safety & Loss Prevention Manager.
  3. Develop/s, implements and monitor/s hospital-wide safety management programs based on evaluation of organizational expertise, applicable law, regulations and accepted practice. Ensures that the hospital complies with relevant laws and safety regulations, JCIA & CBAHI Facility Management & Safety requirements deemed
  4. Establishes an incident reporting system in conjunction with the occurrence variance reporting and tracking system which triggers investigation of all incidents involving property damage, occupational illness, or patient, personnel or visitor injury
  5. Establishes a safety surveillance program involving personnel throughout the facility to identify hazards and unsafe practices
  6. Reviews published and internal reports of failures, hazards, use errors and other deficiencies related to safety management (physical and chemical hazards), life safety management (fire prevention), equipment management (safe medical devices) and utilities management (emergency power).
  7. Reviews summaries of other monitoring activities (quality improvement, infection control).
  8. Prepares and submits annual management reports for Safety & Loss Prevention Department, Facility Management & Safety Committee, and (when required) for outside regulatory agencies.
  9. Represents the hospital in meetings with regulatory agencies that address safety related issues
  10. Coordinates the development, implementation and monitoring of departmental Facility Management & Safety policies and procedures
  11. Develops and conducts formal safety related training programs for the hospital to include:
    1. General safety
    2. Department safety
    3. Specific job-related hazards
    4. Accidents, injury and hazard reporting
    5. Fire and life safety
    6. Smoking regulations
    7. Electrical safety (use of extension cords, frayed cords, broken outlets, broken prongs);
    8. Hazardous materials and waste management programs
    9. External and internal emergency preparedness; and
    10. Occurrence variance reporting
  12. Maintains training records on all of the above safety training programs and reports to Department Heads, Senior Safety Officer, SLP Manager on the compliance rate for attendance at mandatory safety training sessions
  1. Responds to employee, patient and visitor safety concerns by examining safety related issues, preparing recommendations for corrective actions and ensures appropriate follow-up.
  2. Serves as a resource to departments in developing safe working practices and in maintaining a safe working environment
  3. The Safety & Loss Prevention Officer is required to coordinate and monitor the activities of FMS Committee and departments such as those dealing with;
    1. Safety Management
    2. Security Management
    3. Hazardous Materials and Waste Management
    4. Emergency Preparedness
    5. Fire and Life Safety Management
    6. Medical Equipments
    7. Utility Systems
    8. Radiation Safety, Laser Safety
  4. The Safety & Loss Prevention Officer directly evaluates the work of management and other personnel engaged in safety related projects as well as teams, task forces and committees engaged in safety matters
  5. Challenges encountered by the Safety & Loss Prevention Officer include dealing with sensitive issues relating to occupational exposures that have the potential for significant legal liability. The position requires a high degree of inductive/deductive thinking in devising new approaches/innovations to deal with highly complex and/or previously unsolved problems.  The work will often require the application of imaginative and original thinking to deal with new situations that will arise
  6. The Safety & Loss Prevention Officer has the authority to intervene whenever conditions exist that pose an immediate or potential risk to life, health or damage to equipment or the physical environment and to take corrective action as necessary

Photo by West Midlands Police

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