Quality Care and Accreditation Flashcards

Question

who does the joint commission accredit?

Answer 1

health care organizations, including hospitals, home health agencies, long-term care facilities, assisted living programs, ambulatory care providers, laboratory services

Answer 2

ensure quality of care via `performance improvement process, National Patient Safety Goals and identification and prevention of sentinel events and development of program standards

Answer 3

Promote specific improvement in patient safety Highlight problematic areas in health care delivery and offer EB solutions

Answer 4

“unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; require need for immediate investigation and response “

Answer 5

Patient death Paralysis, coma or permanent injury due to medication error Wrong site surgery; Patient commits suicide within 72 hours of being d/c from a hospital setting providing around the clock care

Answer 6

Separate standards for Hospital, Ambulatory Care, Behavioral Health, Home Care and LTC emphasis on pt safety, quality of care, performance improvement

Answer 7

Development of job descriptions, initial and annual competency checklist, quarterly monitoring of staff competency via staff chart audits, compliance audits, observation, peer feedback, patient incident Annual OT competency reassessments to include observation of specific skills related to high volume, high risk procedures Inclusion of OT competency assessments on annual performance evaluations

Answer 8

Develop annual OT competency in-services on environment of care, infection control, age-specific competences, NPSGs Survey OT staff on learning needs and based on survey results, develop inservice training modules. Institute tracking system for all in-services OTs attended, including how they relate to learning needs assessments

Answer 9

credibility of the process Make the accrediting process more continuous Includes document review, interviews, facility inspection and observation of care Provide safe, quality care at all times not just for survey preparation

Answer 10

Maps out/follows care to an active patient Seeks to answer whether the care being provided is Consistent with practice standards, organization’s polices, medical record

Answer 11

Observe actual care given Review medical record of patient whose care was observed Interview providers of care identified in medical record

Answer 12

Environment of care, infection control, staff communication about patient, compliance w/ written policies and procedures

Answer 13

Legibility, timeliness, accuracy, compliance w/ written policies and procedures

Answer 14

Credentials, orientation, competency assessment, review timeliness and content of performance evaluation

Answer 15

Health Care Organization (HCO) demonstrates compliance w/ selected standards used in the surveys conducted under the Early Survey Policy

Answer 16

HCO compliant w/ all standards at the time of the on-site survey or has successfully addressed all requirements for improvement

Answer 17

HCO is not in compliance w/ specific standards & requires follow-up survey w/in 30 days to 6 months

Answer 18

HCO fails to successfully address all requirements of the Accreditation w/ Follow-up Survey decision. In most cases, a follow-up survey in 30 days will be required

Answer 19

Justification to deny due to: threat to health or safety for pts; failure to resolve requirements of Accreditation w/ Follow-up Survey status after 2 opportunities; failure to resolve requirements of Contingent Accreditation status; noncompliance w/ Joint Commission. decision subject to review/appeal before determination to deny accreditation

Answer 20

HCO has been denied accreditation. All review & appeals have been exhausted