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JCIA 2012

Newsletter
International Patient Safety Goals (IPSG)*
The purpose of the IPSGs is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and describe evidence- and expert-based consensus solutions to these problems. Recognizing that a sound system design is needed in the delivery of safe, high-quality health care, the goals encourage organizations to focus on solutions affecting the entire hospital system. There are six IPSG standards with a combined total of 24 measurable elements (MEs). IPSG.1 has 5 MEs while IPSG.5 has 3 MEs; the rest have 4 MEs each. Since there are only 24 MEs, a single Partially met score of 5 shall easily bring down a standards aggregated score to 9.0 or less and the chapters aggregated score to 9.78 or less. The goal is to score a 10 for each of the 24 measurable elements. As with other standards, the IPSGs require that the organization has policies and procedures in place to support the intent of each of these goals. IPSG.1 Identify patients correctly. This standard has a two-fold intent: to reliably identify the individual as the person for whom the service or treatment is intended, and to match the service or treatment to that individual. Reliable identification is ensured by using two patient identifiers full name and birthday. Matching the service or treatment to the correct patient means the patients identification is verified before such treatment or service is provided including administering medication, blood, or blood products, taking blood or other specimens for testing, and other treatment or procedures in outpatient services. What is challenging for TMC: incomplete patient identifiers or use of only 1, wrong patient verification during initial patient encounter, sticking bar code labels on wrong order sheets.
May 11, 2012

IPSG.2 Improve effective communication.

This standard ensures that communication between health care providers is timely, accurate, complete, unambiguous and understood by the recipient. Error-prone communication includes patient care orders or results of critical tests given verbally or through telephone. In such cases, the standards measurable elements require that: a) the order or test result is written by the receiver, b) the written order or test result is read back by the receiver to the giver, and c) the order or test result is confirmed by the individual who gave it.

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What is challenging for TMC: documenting that read-back did occur.

IPSG.3 Improve the safety of high-alert medications. High-alert medications are those with high risk for errors and/or sentinel events and adverse outcomes. High-alert medications also include look-alike/sound-alike drugs. The organization should collaboratively develop its policies and procedures wherein it identifies its own list of high-alert medications based on its own data, and identifies how they will be labeled and stored in such a way that inadvertent administration is prevented. In areas where storage of high-risk medications is allowed, these should be labeled clearly and that they are stored in such a way that access is restricted. Whats challenging for TMC: concentrated electrolytes can still be found in areas where they should not be. IPSG.4 Ensure correct-sight, correct-procedure, correct-patient surgery. Surgeries involving wrong patients, wrong body sites or wrong procedures do happen as a result of ineffective or inadequate communication between members of the surgical team. This IPSG standard ensures that the Universal Protocol s implemented in all applicable areas of the hospital. The standard also calls for policies and procedures governing the implementation and monitoring of the Universal Protocol in settings other than the OR where medical and dental procedures are done. Whats challenging for TMC: documentation that time out do occur, Universal Protocol in applicable out patient areas.

IPSG.5 Reduce the risk of health care-associated infections Proper hand hygiene is an intervention recommended by the World Health Organization and the US Centers for Disease Control and Prevention to prevent common health care-associated infections (HCAIs). The organization has to demonstrate that it has adapted the recommended guidelines and that it effectively implements its hand hygiene program through 100% compliance. This standard also makes sure that policies and procedures for continued reduction of HCAIs are in place and are being followed by the entire organization. Whats challenging for TMC: non-compliance to moments 1 and/or 5, absence of hand-rub dispensers in certain areas IPSG.6 Reduce the risk of patient harm resulting from falls This standard ensures that the organization should evaluate its patients risk for falls and take action to reduce the risk of falling and to reduce the risk of injury should a fall occur. The organization should establish a fall-risk reduction program based on appropriate policies and procedures. Whats challenging for TMC: correct initial assessment and re-assessment, appropriate interventions based on assessment.

JCIA Newsletter 2012


Lead Editor: Dianne Achas Contributors: Jose M. Acuin, M.D. Beth Vargas James Cayabyab Precious Aruelo Michelle Casuga Jen De Dios

*Taken from JCI Accreditation Standards for Hospitals, 4 th edition, pp.35-40

JCIA Newsletter

Ways to Ace the IPSG Standard


The JCI International Patient Safety Goals (IPSG) form the bedrock of patient safety. Their achievement is critical to full compliance with the JCI standards. Because the 6 IPSGs form a separate standards chapter, they greatly impact on the total survey score of Medical City. In addition, the QPS standards require that a monitoring tool is used to track compliance to each of the 6 IPSGs. This issue of the JCI Newsletter is devoted to the JCI IPSGs and their intent statements. The applicability grid that follows the text shows the different areas in the hospital where the 6 IPSGs must be achieved. Goal 3: Improve the Safety of high-Alert Medications (IPSG.3) The organization develops an approach to improve the safety of high-alert medications. Check if your unit or department uses any of the medications included in the DrugWatch list. Place warning labels such as Drug Watch List, Look Alike and Sound-Alike, etc. in the medicine bins. Use Tallman labeling to prevent errors in look-alike and sound-alike drugs. For drugs with sound-alike names, the generic and brand names shall be written together with the indication in order to verify drug identity. Illegible, unclear or incomplete orders shall be verified with the Prescribing Doctor prior to transcription. Use standardized drip whenever possible Use premixed solutions unless otherwise indicated (e.g., concentrated dopamine solutions for congestive heart failure). Telephone and verbal orders are strictly not allowed except for IV follow-up, provided the physician will write and/or countersign the order within 30 minutes. The NIC must verify the illegible and unclear drug orders through the read back process. Orders given by the physician should be read back by the nurse-incharge to ensure proper understanding. In the absence of the NIC, the physician should expect a call from the unit regarding his/her order for clarification. The staff pharmacist will not accept any verbal orders to prepare incorporations of intravenous electrolytes. The intravenous admixture of electrolytes and chemotherapeutic agents will only be prepared by the staff pharmacist upon receipt of the Physicians Order Sheet (POS) and the corresponding charge slips for the request. For incorporations of electrolytes to present intravenous infusions, the staff pharmacist will prepare the quantity of electrolytes to be added to the intravenous infusion upon receipt of the POS and the corresponding charge slip for the request. Pharmacists compound and dispense sodium chloride solutions above 9% (Therapeutics) Dilution and infusion rates are prepared and set by nurse-in-charge as ordered by the attending physician and counter-checked by head nurse prior to administration. (Therapeutics) Use infusion pumps for infusion of chemotherapy and other medication requiring accurate and timely
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Goal 1: Identify Patients Correctly (IPSG.1) The organization develops an approach to improve accuracy of patient identifications. Before giving medications, blood, or blood products; taking blood or other specimens for clinical testing; or providing any other treatments or procedures, tell the patient, Can you please tell me your full name and birth date? I need to confirm it before I perform this procedure on you. Goal 2: Improve Effective Communication (IPSG.2) The organization develops an approach to improve the effectiveness of communication among caregivers. Do not text critical information such as assessment findings and orders. You will never be sure you have been completely understood or that the person you are texting is going to act on the critical information promptly and appropriately. If you must text critical information, make a follow-up call to confirm understanding and effective response to your concerns. When transmitting critical information such as orders or test results verbally OR over the phone, make sure the recipient of your information writes it down completely and legibly (or enters into a computer), reads back the information to you and confirms with you that what has been written down and read back is accurate. Remember: You have effectively communicated to someone only after you are sure you have been understood.

regulation such as aminophyline, heparin, insulin, inotropics and electrolytes and for critically-ill patients. (NSD manual) Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery (IPSG.4) The organization develops an approach to ensuring correct-site, correct-procedure, and correct-patient surgery. 1. The correct operation and site of the operation should be specified when the procedure is scheduled, should be noted on the record of the history and physical examination and should be specified on the informed consent. Anyone reviewing the schedule, consent, history and physical examination, or reports documenting the diagnosis, should check for discrepancies among all those parts of the patients record and reconcile any discrepancies with the surgeon when noted. All information that should be used to support the correct patient, operation, and site, including the patients or familys verbal understanding, should be verified by the nurse and surgeon before the patient enters the OR. Any discrepancies in the information should be resolved by the surgeon, based on primary sources of information, before the patient enters the OR. All verbal verification should be done using questions that require an active response of specific information, rather than a passive agreement. The site should be marked by a healthcare professional familiar with the facilitys marking policy, with the accuracy confirmed both by all the relevant information and by an alert patient or patient surrogate if the patient is a minor or mentally incapacitated. The site should be marked by the providers initials. The site mark should be visible and referenced in the prepped and draped field during the time-out. All information that should be used to support the correct patient, operation, and site, including the patients or familys verbal understanding, should be verified by the circulating nurse upon taking the patient to the OR. Separate formal time-outs should be done for separate procedures, including anesthetic blocks, with the person performing that procedure. All noncritical activities should stop during the time-out. Verification of information during the timeout should require an active communication

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of specific information, rather than a passive agreement, and be verified against the relevant documents. All members of the operating team should verbally verify that their understanding matches the information in the relevant documents. The surgeon should specifically encourage operating team members to speak up if concerned during the time-out. Operating team members who have concerns should not agree to the information given in the time-out if their concerns have not been addressed. Any concerns should be resolved by the surgeon, based on primary sources of information, to the satisfaction of all members of the operating team before proceeding.

Goal 5: Reduce the Risk of Health CareAssociated Infections (IPSG.5) The organization develops an approach to reduce the risk of health careassociated infections.

2.

Habit
Always wash in and wash out upon entering/exiting a patient care area and before and after patient care Make washing hands a habit as automatic as looking both ways when you cross the street or fastening your seat belt when you get in your car

Active Feedback
Coach and intervene to remind staff to wash hands. Provide real time performance feedback Clearly state expectations about when to sanitize hands to all staff members Communicate frequently provide visible reminders and ongoing coaching to reinforce effective hand hygiene expectations Celebrate improved hand hygiene

3.

4.

No One Excused
Protect the patient and the environment everyone must wash in and wash out Make it comfortable to wash hands with soap or use waterless hand sanitizer Hold everyone accountable and responsible doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists Apply progressive discipline from the top managers must hold everyone accountable for proper hand washing Commit to achieve hand hygiene compliance of 90+ percent Serve as a role model by practicing proper hand hygiene Make it easy; examine work flow of health care workers to ensure ease of washing hands: Provide easy access of hand hygiene equipment and dispensers

5.

6.

7. 8.

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Create a place for everything: for example, a health care worker with full hands needs a dedicated space where he or she can place items while washing hands Limit entries and exits from a patients room make supplies available in room and eliminate false alarms that require staff to leave room to turn alarm off Goal 6: Reduce the Risk of Patient Harm Resulting from Falls (IPSG.6) The organization develops an approach to reduce the risk of patient harm resulting from falls. Review medications, especially high- risk medications, such as sedatives, antidepressants, antipsychotics and centrally acting pain relief. Assess and manage bone health in older people who have, or who are at risk of, low-trauma fractures. This includes the use of vitamin D and calcium, as well as formal treatments for osteoporosis. Check lying and standing blood pressure in older patients at risk of falls. Ensure that acutely confused patients are investigated for the cause of the delirium, and contribute to the clinical management plan for managing confused older patients. Avoid using physical or chemical restraints, where possible. If a patient falls while in hospital, examine them and investigate the fall as needed. Assess the patients risk of falling in future, and provide individualized interventions to minimize this risk. Ensure that older patients have their usual spectacles and visual aids in hand. Organize routine screening urinalysis to identify urinary tract infection. Organize routine physiotherapy review for patients with mobility difficulties: Communicate to staff and the patient the limits of the patients mobility status using written, verbal and visual communication Put walking aids on the side of the bed that the patient prefers to get up from, and, where possible, assign a bed that allows them to get up from their preferred side Supervise or help the patient if required Make sure that, while mobilizing, the patient wears fitted, nonslip footwear (discourage the patient from moving about in socks, surgical stockings or slippers)

JCIA Newsletter

TMC iNSTYLE
the Project JCi Wear T-shirt Design Competition and Fashion Show

Last May 3, 2012, the TMC community feasted their eyes on one of a kind fusion of fun, beauty, creativity
and fashion as carefully selected models from various departments strut their way on the fashion ramp for the first ever Project JCi Wear Fashion Show. The show is the first of the many events that the Medical Quality Improvement Office and its partner departments have planned and organized this year in preparation for the JCI re-accreditation in November. As early as the day before, our Facilities and Housekeeping staff were seen constructing and decorating the specially-designed catwalk at the Foyer where the event was held. Blue and yellow balloons, life-size standees of the models, and multi-colored lights adorned the venue. Staff, patients and visitors alike felt the excitement as soon as the upbeat music signaled the start of the show. The audience swelled shortly thereafter upon seeing the events celebrity hosts, Maverick Only (of Totoo TV fame) and CRDs Ella Lacson. Four departments gamely participated and expressed their support and commitment to JCIA by designing artistically crafted T-shirts modeled by their own staff. These departments were Admissions, Cathlab, Medical Information, and Systems and Quality. The Admitting Department bagged all the major prizes including the Best T-shirt design (by Ms. Lourdes Zabala) and the Best Male and Female Models (Vermont Ventura and Lou Angielyn Cruz). The winning design shall be used as inspiration for the 2012 TMC anniversary shirt. See you all again in July for our next mega event, JCi Rock! Watch out for announcements!

Whats out for JCi Rock:

TMCno sikat?!

Calling all TMC bands! Join our rock band contest at ipakita na kayo ang sikat!If your band has 5-7 members, you qualify. We will provide the lyrics, you provide the music. Submit your demo recording and be ready to perform your song during the JCi Rock event in July. Amazing, amazing prizes are in store! Interested parties may inquire at MQIO or CHI. Posters and announcements will be released very, very soon.

Question No. 1

JCi wear female models. L-R: Jean (MID), Lou (Admissions); Mich (Cathlab); & Cathy (SQD)

In what 2 standards did TMC obtain a perfect 10 in 2009 Survey?

JCi Wear First Place Winners, Lourdes Zabala and models Vermont Vergara & Lou Angielyn Cruz receiving their award from Ms. Margaret Bengzon and Dr. Jose Acuin,

JCi Wear Hosts: Mr. Maverick Only & Ms. Ella Lacson.

Question No. 2

What are the names of the 3 JCI surveyors who visited TMC last 2009?

JCi wear male models. L-R: Jonathan (MID), Vermont (Admissions); Ram (Cathlab); & Chester (SQD)

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