JCAHO’s new accreditation program

Today’s blog features comments from Dr. Walter Ettinger, president of UMass Memorial Medical Center that appeared in Advance for Health Information Executives magazine:

“JCAHO’s new accreditation program rolled out this year and UMass Memorial was one of the first hospitals to undergo the new periodic performance review. Two specific changes in the review were clear: the use of the tracer methodology and the focus on the National Patient Safety Goals.

Under the tracer methodology, specific patients are selected by the surveyors and tracked within the organization to assess quality and safety of care. Surveyors evaluate the care delivered by each department as well as how departments work together as a whole. In addition, the tracer methodology puts the survey spotlight on staff members.

We also realized that with emphasis on National Patient Safety Goals, we would have to sharpen our focus on safety. From the self-assessment, we knew that surveyors would be investigating procedures such as the frequency of handwashing, patient identification before administering medication or drawing blood and use of improper abbreviations when writing medication orders.

In our view, the new survey process would require some major changes in staff behavior and our organization would be on the receiving end of a thorough, comprehensive JCAHO review. We had to prepare.”

Thank you, Dr. Ettinger!

Eliminating medication reconciliation errors

JCAHO recently released a new alert that urges intensified attention to the accuracy of medications given to patients as they transition from one care setting to another, or one practioner to another.

According to the alert, medication reconciliation should occur whenever a patient moves from one location to another in a healthcare facility; or from one healthcare facility to another or to home; and/or when there is a change in the caregivers responsible for the patient.

Last year, United States Pharmacopeia received more than 2,000 voluntary reports of medication reconciliation errors and an Institute of Medication report estimates more than 7,000 deaths per year in hospitals due to medication errors. Most of the medical errors resulting in death were due to a breakdown in communication, and approximately half would have been avoided through effective medication reconciliation.

To reduce the risk of reconciliation errors, JCAHO advises organizations to:

* put the list of medications in a highly visible place with information about dosages and schedules
* reconcile medications at each interface of care
* communicate a complete list of patient medications to the next service provider
* provide patients with a complete list of medications they will take after being discharged, with instructions on how long to take them