01 Implementing the International Patient Safety Goals (IPSG)
JCI focuses specifically on the following 7 areas,*** there are 7 standards with 24 elements of measurement, and the IPSGs are part of the core standards that must be achieved and are a one-vote decision.
1). Correct identification of patients: we develop standardized documents to clarify the two bases of identification (name + date of birth), the scope of the use of wristbands, etc., emphasizing that whether it is infusion, administration of medication, treatment or other operations, the patient's identity confirmation in addition to medical staff correctly ask the patient's name, but also must be checked with the patient or family members *** with the date of birth. It is also required to ensure that the patient's name and date of birth must be on all medical documents.
2). Improve the effectiveness of communication and eliminate adverse events caused by poor communication. Our hospital has made it clear that verbal medical advice can only be used for resuscitation patients. Inspection, ultrasound, electrocardiography, endoscopy room and other medical and technical examination room to release the critical value of the project and the scope of the project, such as blood glucose adults <2.5, > 22.2 must be notified to the clinician within 10 minutes. Nurses are required to strictly follow the procedure of recording-repeating-confirming-reporting when executing verbal medical instructions and receiving critical value reports, and doctors should have treatment measures within 30 minutes after receiving critical value reports and record them in the medical record. The establishment of a rescue patient record sheet, critical value register, important telephone communication book.
3). Ensure that the patient is correct, the correct surgical site, the requirements of surgery or other operations before the official start of the implementation of the "time out" program, we designed a surgical patient handover, record sheet, the patient's preoperative preparation, identification of surgical site and arrival time in the operating room, intraoperative and post-operative resuscitation room conditions through a form for the whole process of recording; in order to make the operational standards consistent In order to make the operation standard consistent, we made the teaching video of operation time out, the pictures of how to mark different operation parts, and stipulated which kind of marker pen to use.
4). High-risk drug management: the logo is uniform throughout the hospital, with special warning labels for high-risk drugs, look-alike drugs, and drugs with similar names; each unit has a clear catalog of high-risk drugs, and except for the operating room, the rest of the units are not allowed to store potassium chloride, which is uniformly configured centrally by the static dispensing center. The temperature and humidity requirements of the drug storage environment have been stipulated, and the safety of the storage environment is routinely monitored every day. Drugs are required to have a daily handover record, and a directory of drugs that must be double-checked and signed by the executive is published, such as the use of high-concentration electrolytes, insulin, and chemotherapeutic drugs. The record of use must be consistent with the doctor's orders and prescriptions, and at the same time coincide with the pharmacy's outgoing records.
5). Strictly enforces the hospital infection prevention and control system to reduce the risk of healthcare-associated infections. Emphasize the importance of hand hygiene, hang hand washing flow charts on every hand washing sink, equipped with hand sanitizer and hand wipes. In the elevator room, ward entrance, treatment trolley, nursing trolley, oral medication trolley, etc. are equipped with rapid hand disinfectant, play hand-washing video, to improve the rate of hand-washing of staff and than the patients and family members.
6). Prevention of inpatient falls (bed fall) occurs, all patients, including outpatients are assessed for fall risk, design a special assessment and reassessment sheet, timely detection of high-risk groups to take interventions to prevent the occurrence of bed falls, falls. We require falling patients to wear special color wrist tags, hang fall prevention signs at the entrance of wards and at the bedside, and design special fall prevention leaflets to be distributed to high-risk patients and their families, so as to reduce the incidence of bed fall and falls. For pediatric patients, we use special beds to reduce the occurrence of pediatric bed falls.
7). Establishment of quality monitoring plan, implementation of patient safety goals, continuous improvement: for each safety goal, the development of quality monitoring plan, such as the correct implementation rate of patient identification before intravenous infusion administration, the implementation rate of hand hygiene, the incidence of inpatient falls, the rate of timely reporting of critical values, the correct implementation rate of time-out, etc., each of which has a target value, and each month the responsible person to collect and analyze the data, analyze the causes, submit an analysis report, and carry out quality control. Each month, the responsible person collects and analyzes the data, analyzes the reasons, submits an analysis report, and carries out continuous quality improvement.
02 Implementation of systematic nursing assessment, to provide the basis for the implementation of personalized care plan
Patient assessment (AOP) is also an important chapter in the JCI standards, and it is also one of the difficult points for us. While coping with a large number of treatment tasks, it is required to assess the patient in a timely and correct manner to develop a care plan. It undoubtedly increases the workload of clinical nursing staff. Our hospital has formulated the "Nursing Assessment System" and designed the "Admission Nursing Assessment Sheet" as the initial assessment of newly admitted patients, and then based on the problems existing in the initial assessment, we have designed the assessment record sheet for pain, falls, pressure sores, restraints, special populations, terminally ill patients, etc., which is specially designed to pass through the tabular format, so that the nursing staff can have a comprehensive understanding of the patient's condition, discover problems in time, and formulate a practicable and personalized nursing care The program is designed to enable nursing staff to have a comprehensive understanding of the patient's condition and formulate practical and individualized care plans. In order to promote the assessment system, through the organization of training, on-site guidance, template form production, quality control plan, "admitted patients pain screening completed in a timely manner" as a monitoring plan for continuous improvement.
03 Safeguarding the rights of patients and families
It is difficult to cover all aspects of the section that is most vulnerable to demerit points. We because of the stomatology department of the various clinic interval sound effect is not good, by the prosecutor that did not protect the patient's privacy was deducted points. The main emphasis on entering the ward to knock first; ward with a special recycling with patient information waste paper with a lock plastic box; infusion after the recovery of the patient's name on the empty bottle need to cover; patients out of the examination of medical records need to be used in the delivery of medical records bag containers; the ward has a special doctor-patient communication room; elevator room affixed to the "do not talk about the condition of the" sign; clinic The outpatient clinic must do one person, one room, close the door and so on, to protect the privacy of patients. For places where it is difficult to protect privacy, such as emergency infusion rooms, operating rooms, etc., we post reminders to inform patients that they can make requests if they have special needs. To ensure the rights of patients and their families, we sign a general informed consent form on admission, informing the hospital of the norms and diagnostic and treatment needs, and at the same time, issue the patient's rights and obligations of the education sheet.
04 Patient health education is comprehensive and holistic
JCI is concerned that hospitals provide patients with effective health guidance to facilitate their recovery and subsequent treatment. We design health education record sheets for different specialties, such as internal medicine, surgery, pediatrics, obstetrics, etc., based on the assessment of the learning needs of patients and their families, based on the patient's `disease needs to develop a health education plan, record the time of implementation and evaluation of the effect. Colorful health education leaflets were produced according to the common diseases of different specialties and placed in all corners of the hospital. For the production and updating of health education leaflets, we are unified by the hospital health education team layout, numbering, content review, to ensure that the standardization of the leaflets and scientific.
05 Strict nursing staff qualification and competency assessment, training and evaluation
JCI focuses on the qualifications of nursing staff and the education and training given by the hospital to ensure that nurses are capable of serving patients. The hospital's medical and nursing staff are CPR licensed, and nurses in special positions, such as the emergency room, intensive care unit, resuscitation room, operating room, etc., must hold an ACLS training certificate, which is valid for two years. For new nursing staff must receive fire, hand hygiene, CPR, international safety goals and other essential knowledge training, assessment and qualification before they can be on duty, independent on duty before the need to accept the appropriate specialized training and assessment before they can work; each nursing staff must sign the job description, the hospital and the Department of Nursing should be based on the requirements of the job description to provide professional training and assessment. The hospital should confirm the authenticity of each nurse's qualifications, such as academic qualifications, professional titles, practicing certificates and so on.
06 Establish a culture of continuous quality improvement
JCI believes that the task of quality management is not only to identify problems and eliminate staff errors and other hazards, but also more importantly, to establish a safer system through continuous quality improvement, we have learned through the JCI accreditation and the establishment of a culture of continuous improvement of the quality of nursing care, each nursing unit is to take the lead in the monitoring of quality indicators. Each nursing unit carries out quality index monitoring, takes the lead in carrying out PDCA improvement and quality control circle activities in the hospital, participates in the failure mode analysis project for chemotherapy drugs in the hospital; implements the non-punitive abnormal event reporting system, takes the initiative to report nursing adverse events; creates a neat medical environment through 5S management in each ward; ICU implements the standard preventive measures for VAP in patients undergoing ventilator treatment in the cluster management, and effectively reduces the occurrence of VAP. The ICU has implemented a cluster management of standardized preventive measures for VAP in patients on ventilator therapy, effectively reducing the occurrence of VAP.