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Standard I

              A qualified individual conducts a preanesthesia assessment.

Intent of I

Because anesthesia carries a high level of risk, its administration is carefully planned. The patient's preanesthesia assessment provides information needed to

* Select the anesthesia and plan anesthesia care;

* Safely administer an appropriate anesthetic; and

* Interpret findings of patient monitoring.

An anesthesiologist of other qualified individual conducts the preanesthesia assessment.

The preanesthesia assessment process is carried out in a shortened time frame when an emergency requires anesthesia.

Measurable Elements of I

1- A preanesthesia assessment performed for each patient before anesthesia induction.

2- A qualified individual performs the assessment.

Standard II

Each patient's anesthesia care is planned and documented.

Intent of II

Anesthesia care carefully planned and documented in the anesthesia record. The plan considers information, other medications and fluids, monitoring procedures, and anticipated post anesthesia care.

Measurable Elements of II

1- The anesthesia care of each patient is planned.

2- The plan is documented.

Standard III

      The risks, potential complications, and options are discussed with the patient, his or her family, or those who make decisions for the patient.

Intent of III

The anesthesia planning process includes educating the patient, his or her family, of decision maker on the risks, potential complications, and options related to the planned anesthesia and postoperative analgesia. This discussion occurs as part of process to obtain consent for anesthesia as required in PFR9.4. The anesthesiologist or the qualified individual who will administer the anesthesia provides this education.

Measurable Element of III

1- The patient, family, and decision-makers are educated on the risks, potential complications, and options of anesthesia.

2- The anesthesiologist or other qualified individual provides the education.

 Standard IV

The anesthesia used is written in the patient record.

Intent of IV

 The anesthesia used and the anesthetic technique are entered in the patient's anesthesia record.

Measurable Element of IV

The anesthesia used and the anesthetic technique are entered into the patient's anesthesia record.

Standard V

Each patient's physiological status during anesthesia administration is continuously monitored and written in the patient's record.

Intent V

Physiological monitoring provides reliable information about the patient's status during the administration of anesthesia and the recovery period. Monitoring methods depend on the patient's preanesthesia status, anesthesia choice, and complexity of the surgical or other procedure status, anesthesia choice, and complexity of the surgical or other procedure performed during anesthesia. In all cases, however, the monitoring process is continuous, and the results are entered into the patient's record.

Measurable Elements of V

1- Physiological status is continuously monitored during anesthesia administration.

2- The results of monitoring are entered into the patient's anesthesia record.

Standard VI

 Each patient's post anesthesia status is monitored and documented, and a qualified individual discharges the patient from the recovery area using established criteria.

Intent of VI

Monitoring during anesthesia is the basis for monitoring during the post anesthesia recovery period. The ongoing, systematic collection and analysis of data on the patient's status in recovery support decisions about moving the patient to other settings and less intensive services.

Recording of monitoring data provides the documentation to support discharge decisions.

The anesthesiologist or other qualified individual decides whether the patient can be discharged from the recovery area to another level of care of from the organization (as in the case of ambulatory anesthesia). Standardized criteria developed by medical staff are used to make discharge decisions. The time of arrival and discharge from the recovery area are record.

Measurable Elements of VI

1- Patients are monitored appropriate to their condition during the post anesthesia recovery period.

2- Monitoring findings are entered into the patient's record.

3- Established criteria are used to make discharge decisions.

4- A qualified individual applies the criteria and discharges the patient.

5- Recovery area arrival and discharge times are recorded.

Standard VII

Equipment, supplies, and medications recommended by anesthesia professional organizations or by alternative authoritative sources are used

 Intent of VII

Anesthesia risks are significantly reduced when appropriate and well functioning equipment is used to administer anesthesia and monitor the patient. Adequate supplies and medications are also made available for planned use and emergent situations. Each organization understands the required or recommended equipment, supplies, and medications necessary to provide anesthesia services to its patient population. Recommendations on equipment, supplies and medication can come from a government agency, national or international anesthesia professional organization, or other authoritative sources.

Measurable Elements of VII

1. Recommended equipment is used.

2. Recommended supplies are used.

3. Recommended medications are used.

Ms 1: When medical staff clinical departments exist.

Ms 1.1: Each department has effective leadership.

Ms 1.1.1: The director of each department is certified by an appropriate specialty board, of affirmatively establishes comparable competence, through the credentialing process.

Ms 1.2: Medical staff department directors' responsibilities are specified in the medical staff bylaws and rules and regulations.

Ms 1.2.1: Each department director is responsible for the following.

Ms 1.2.1.1: All clinically related activities of the department.

Ms 1.2.1.2: All administratively related activities of the department, unless other wise provided for by the hospital.

Ms 1.2.1.3: Continuing surveillance of the professional performance of all individuals in the department who have delineated clinical privileges.

MS 1.2.1.4: Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the department.

MS1.2.1.5: Recommending clinical privileges for each member of the department.

MS1.2.1.6: Assessing and recommending to the relevant hospital authority off-site sources for needed patient care services not provided by the department or the organization.

MS1.2.1.7: The integration of the department or service into the primary functions of the organization.

MS1.2.1.8: The coordination and integration of interdepartmental and intradepartmental services.

MS1.2.1.9: The development and implementation of policies and procedures that guide and support the provision of services.

MS.1.2.1.10: The recommendations for a sufficient number of qualified and competent persons to provide care or service.

MS1.2.1.11: The continuous assessment and improvement of the quality of care and services provided.

MS 1.2.1.12: The maintenance of quality control programs, as appropriate.

MS1.2.1.13: The orientation and continuing education of all persons in the department of service.

MS1.2.1.14: Recommendations for space and other resources needed by the department of service.

MS2: The organization establishes mechanisms for hospital-specific appointment and reappointment of medical staff members and for granting and renewing of revising hospital-specific clinical privileges.

MS2.1.1: Medical staff membership is oriented to these bylaws, rules and regulations. And policies and agrees in writing that his or her activities as a medical staff member will be bound by them.

MS2.2: There are mechanisms, including a fair hearing and appeal process for addressing adverse decisions for existing medical staff members and other individuals holding clinical privileges for renewal, renewal, revocation, or revision of clinical privileges.

MS2:4:3:  Each clinical department makes recommendations to the medical staff regarding professional criteria for clinical privileges.

1. Each page in the record contains the patient's name of ID number.

2. Personal biographical data include the address, employer, home and work telephone numbers, and mantel status.

3. All entries in the MR. contain the author's identification. Author identification may be a hand written signature, or a unique electronic identifier.

4. All entries dated.

5. The record is legible to someone other than the writer.  A second surveyor examines any record judged to be illegible by one physician surveyor.

6. Significant illnesses and medical conditions are indicated on the problem list.

7. Medication allergies and adverse reactions are prominently noted in the record. If the patient has not known allergies or history of adverse reactions, is appropriately noted in the record.

8. Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.

9. For patients 14 years and older, there is appropriate notation consuming the use of cigarettes, alcohol, and substances (for patients seen three or more times, query substance abuse history).

10. The history and physical exam identifies appropriate subjective and objective information pertinent to the patient's presenting complaints.

11. Laboratory and other studies are ordered, as appropriate.

12. Working diagnoses are consistent with findings.

13. Treatment plans are consistent with findings

14. Encounter forms of notes have a notation, when indicated, regarding follow-up care, calls, of visits. The specific time of rectum is noted in weeks, months, of as needed.

15. Unresolved problems from previous office visits are addressed in subsequent visits.

16. Review for underutilization and over utilization of consultants and timely use of consultant.

17. If a consultation is requested, is there a note from the consultant in the record?

18. consultation, lab, and imaging reports filed in the chart are initialed by the PCP to signify review and show timely follow up. Review and signature by professional's anther than PC's such as nurse practitioners and physician assistants, do not meet this requirement. If the reports are presented electronically. Or by some other method, there is also representation of physician review. Consultation, abnormal lab, and imaging study results have an explicit notation in the record of follow up plans.

19. There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic problem.

20. An immunization record for children is up to date, or an appropriate history has been made in the medical record for adults.

21. There is no evidence that preventive screening and services are offered in accordance organization's practice guidelines.

A Significant advice given by telephone is recorded

B Evidence of appropriate patient education about diagnoses and treatment is documented.

The leader is responsible for directing the team and managing the problem solving session. He or she leads the members through the various activities required to achieve the objectives of each of the steps in the process.

The leader must also ensure that all members participate in the session. This may involve bringing in quiet members and shutting out those who are dominating the discussions.

When the problem-solving process is used in family groups, the manager does not automatically become the leader. Any member of the group may assume the role. In fact, all members should have several opportunities to try their hand at this demanding role.

The effective leader balances two major elements the task and the people. The lists below give some specific behaviors that leaders can use; the items are taken from Small Group Problem.

 - Ask for Facts, opinions, suggestions, of any other information that will promote team discussion.

- Allow time for silence in order to provide a comfortable environment for thinking

- focus the team's attention on what needs to be done.

- Summarize major points and restate related themes or ideas.

- Encourage discussion of difficulties that the team may experience while working effectively toward accomplishing goals.

- establish relationships among deferent ideas.

- Compare team decisions and accomplishments with team goals and standards.

- Increase enjoyment and ease tensions by suggesting breads, making jokes, and proposing fun approaches to team work.

- share personal feelings about the way the team is working.

- Encourage members to be open, to be individualistic, and to take risks.

- Study the process followed in the team and use these observations to evaluate team effectiveness.

The scribe is responsible for recording the team's ideas, decisions, and recommendations. He or she maintains the "team memory".

The scribe usually works at a flipchart easel. The scribe's printing should be legible and large enough for everyone in the team to read. The charts should be labeled or titled (e.g., "Problems under Consideration"; " Step 3: Potential Solutions") and numbered. Some scribes change the color of their markers when they move from one step to another (e.g., black for even numbered steps, blue for odd). All of these make it easy to reconstruct the team's thought process (e.g., for typing minutes) or to review where the team left off for the beginning of the next problem-solving session.

As each flipchart page is filled, the scribe posts it so that team members can go back and review at any time. The scribe is responsible for the tacks, tape, or other supplies required posting the charts.

The way a scribe goes about maintaining the team memory will effect how well the team works.

Here are some guidelines for using the "power of the pen" constructively:

- Record the ideas or suggestions verbatim. If the idea is too long to record all of it, write down the key words used by the suggester. You may have to test understanding to ensure that you heard and understood the individual's suggestion. In brainstorming sessions, do this as quickly as possible; otherwise the team will lose its momentum. There will be time to clarify and react to the ideas later. Do not, under any circumstances, interpret the individual's idea or put words into his or her mouth. What's on the flip chart then becomes the scribe's memory, not the teams.

Use two scribes. Particularly when freewheeling; teams can produce ideas faster than one person can write. Have a second scribe (and a second flipchart stand) to record every other suggestion.

Always be ready to write. In brain storming, write numbers or bullets down the left, to give the impression that you're waiting for the next idea. When you get near the bottom of the sheet tear it off and be prepared to start writing on the next page. Many teams sense an "end" to brainstorming when the page filled; scribes who are reluctant to turn the page and use more paper confirm this impression.

Bracket ([ ]) ideas that are set aside during list reduction, rather than crossing them out. Bracketing ideas is less final, and less judgmental, than crossing them out; allow the team to return to the bracketed ideas later if needed.

Take your turn. In brainstorming, the scribe either takes his\her turn (round robin) or waits until late in the session (free wheeling) to add ideas the list.

In problem solving training, teams have a

 limited amount of time for applying the steps of process during practice exercises. In the actual work environment, family groups will also have time constraints. To help teams manage their time effectively, most agree on a game plan how long to spend on each of the activities or each of the steps of the process.

The time keeper is assigned responsibility for:

* leading the initial discussion to allocate time to the tasks.

* Monitoring how long the team is taking to accomplish its tasks.

* Giving regular up dates to make team members aware of where they are.

The team may decide to reallocate its time as the task progresses. It may even decide not to complete the task within the time limit. These are team decisions not the time keeper's individual choice.

In some problem solving training it may be necessary to divide family groups into two or three subgroups. To share across subgroups, the presenter role may be assigned to one of the members of each subgroup.

The presenter's role is to explain briefly (usually 10to 15 minutes) how his or her subgroup worked through the process and what decisions were reached. The presenter (who should be someone other than the leader or scribe) should:

* Take notes throughout the session, so that the presentation is already outlined when the session ends.

* Review the notes with the subgroup, to ensure that they are correct and that nothing has been left out.

* use the subgroup's flipcharts recorded by the scribe.

* focus on the process steps, the tools and techniques, and the use of interactive skills. In training situations, the results are less important than the application of the discipline.

In applying problem solving on the job, it may be necessary to make a presentation on the team's progress or recommendations (e.g., to the family group manager's manager). These presentations tend to be longer and some what more elaborate than those in training, and several team members may each be responsible for parts of the presentation.

Standard COP10: Each patient's surgical care is planned and documented, based on the results of the assessment

Measurable Elements of COP10:

1. Each patient's surgical care is planned.

2. The planning process considers all available assessment information.

3. The planned surgical care is documented.

4. A preoperative diagnosis is documented.

Standard COP10.1: The risks, benefits, potential complications, and options are discussed with the patient and his or her family or those who make decisions for patient.

Measurable Elements of COP10.1:

1. The patient, family, and decision makers are educated on the risks, benefits, potential complications, and options related to the planned surgical procedure.

2. The education includes the need for, risk of, and alternatives to blood and blood product use.

3. The patient's surgeon or other qualified individual provides the education.

Standard COP10.2: the surgery performed is written in the patient record.

Measurable Elements of COP10.2:

1. A postoperative diagnosis is documented.

2. A description of the surgical procedure, findings and any surgical specimens is documented.

3. The names of the surgeon and surgical assistants are documented.

4. The surgical report is available within a time frame needed to provide post surgical care to the patient.

Standard COP10.3: Each patient's physiological status is continuously monitored during and immediately after surgery and written in the patient's record.

Measurable Elements of COP10.3:

1. The patient's physiological status is monitored continuously during surgery.

2. The patient's physiological status is monitored during the immediate post surgery period.

3. Findings are entered into the patient's record.

Standard COP10.4: Patient care after surgery is planned and documented.

Measurable Elements of COP10.4:

1. Each patient's medical, nursing, and other post surgical care is planned.

2. The plan(s) is documented in the patient's record.

Standard AOP.1: All patients cared for by the organization have their health care needs identified through an established assessment process.

Measurable Elements of AOP.1:

1. Organization policy and procedure define the information to be obtained for inpatients and ambulatory patients.

2. Organization policy and procedure define who performs the assessment.

3. Organization policy identifies the information to be documented as the patient enters the organization.

Standard AOP.1.1: The organization has determined the scope and content of assessments, based on applicable laws and regulations.

Measurable Elements of AOP.1.1:

1. The scope and content of assessments by each discipline are defined in writing.

2. Only those individuals permitted by licensure, applicable laws and regulations, or certification perform the assessments.

3. The assessment activities performed in different settings are defined in writing.

Standard AOP.1.2: Clinical practice guidelines, when available and adopted by the organization, are used to guide patient assessment reduce unwanted variation.

Measurable Elements of AOP.1.2:

1. Organization and clinical leaders set criteria to select clinical practice guidelines.

2. Organization and clinical leaders adapt guidelines as appropriate to the organization's patients and resources.

3. When available and adopted, guidelines are used to guide the assessment of patients for whom the guideline applies.

4. Guidelines are regularly reviewed after implementation.

Standard AOP.1.3: assessments are completed in the time frame proscribed by the organization.

Measurable Elements of AOP.1.3:

1. Appropriate time frames for performing assessments are established for all settings and service.

2. Assessments are completed within the time frames established by the organization.

3. The findings of assessments performed outside the organization are verified at admission.

Standard AOP 1.4.: Assessment findings are documented in the patient's record and readily available to those responsible for the patient's care.

Measurable Elements of AOP.1.4:

1. Assessment findings are documented in the patient's record.

2. Those caring for the patient can find and retrieve assessments as needed from the patient's record.

Standard AOP.2: Each patient's initial assessment includes an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history.

Measurable Elements of AOP.2:

1. Each patient admitted has an initial assessment that meets organization policy.

2. Each patient receives an initial physical assessment.

3. The physical assessment includes a physical exam and health history.

4. Each patient receives an initial psychological assessment.

5. Each patient receives an initial social and economic assessment.

6. The initial assessment results in understanding the care the patient is seeking.

7. The initial assessment results in selecting the best setting for the care.

8. The initial assessment results in an initial diagnosis.

9. The initial assessment results in understanding any previous care.

 Standards

        AOP.2.1 The patient's medical and nursing needs are identified from the initial assessment.

AOP.2.1.1 The initial medical assessment is documented in the patient's record within the first 24 hours after the patient's entry

AOP.2.1.2 The initial medical assessment is documented before anesthesia or surgical treatment.

AOP.2.1.3 The initial medical assessment of emergency patients is appropriate to their needs conditions.

AOP.2.1.4 The initial nursing assessment is documented in the patient's record within the time frame established by the organization.

Measurable Elements of AOP.2.1:

1. The initial assessment results in the identification of the patient's medical needs.

2. The initial assessment results in the identification of the patient's nursing needs.

Measurable Elements of AOP.2.1.1:

1. The initial medical assessment is documented in the patient's record within the first 24 hours of admission.

2. Initial medical assessments conducted outside the organization are no older than 30 days.

3. Any significant changes in the patient's condition since the report are noted in the patient's record.

Measurable Elements of AOP.2.1.2:

1. Surgical patients have a medical assessment performed before surgery.

2. The medical assessment of surgical patients is documented before surgery.

3. Surgical patients have the results of diagnostic tests recorded before surgery.

4. Surgical patients have a preoperative diagnosis recorded before surgery.

5. The anesthesia assessment determines if the patient is appropriate candidate for the planned anesthesia.

6. Patients are reevaluated immediately before the induction of anesthesia.

7. An anesthesia assessment note is recorded before the use of anesthesia.

Measurable Elements of AOP.2.1.3:

1. for emergency patients, the medical assessments is appropriate to their needs and condition.

2. If surgery is performed, there is at least a brief note and preoperative diagnosis recorded before surgery.

Measurable Elements of AOP.2.1.4:

The initial nursing assessment is documented in the patient's record in a time frame that meets organization policy.

Standard AOP.2.2: Patients are screened for nutritional status and functional needs and are referred for further assessment and treatment when necessary.

Measurable Elements of AOP.2.2:

1. Qualified individuals develop criteria to identify patients who require further nutritional assessment.

2. Patients are screened for nutritional risk as part of the initial assessment.

3. Patients at risk for nutritional problems according to the criteria receive a nutritional assessment.

4. Qualified individuals develop criteria to identify patients who require further functional assessment.

5. Patients are screened for their need for further functional assessment.

6. Patients in need of a functional assessment according to the criteria are referred for such an assessment.

Standard AOP.2.3: The organization conducts individualized initial assessments for special populations cared for by the organization.

Measurable Elements of AOP.2.3:

1. The organization identifies those patient populations and special situations for which the initial assessment process is modified.

2. These special patient populations receive individualized assessments.

Standard AOP.2.4: The initial assessment includes determining the need for discharge planning and additional specialized assessment.

Measurable Elements of AOP.2.4:

1. A process is in place to identify those patients for whom discharge planning is critical.

2. When the need for additional specialized assessments is identified, patients are referred.

Standard AOP.3: All patients are reassessed at appropriate intervals to determine their response to treatment and to plan for continued treatment of discharge.

Measurable Elements of AOP.3:

1. Patients are reassessed to determine their response to treatment.

2. Patients are reassessed to plan for continued treatment or discharge.

3. Patients are reassessed at intervals appropriate to their condition, plan of care, and individual needs or according to organization policies and procedures.

4. Reassessment is documented in the patient's record.

Standards

 AOP.4: Qualified individuals conduct the assessments and reassessments.

AOP.4.1: Assessment and reassessment responsibilities are defending in writing.

Measurable Elements of AOP.4:

1. Individuals qualified to conduct patient assessments and reassessments are identified by the organization.

2. Emergency assessments are conducted by individuals qualified to do so.

3. Nursing assessments are conducted by individuals qualified to do so.

Measurable Elements of AOP.4.1:

Those qualified to conduct patient assessments and reassessments have their responsibilities defined in writing.

Accreditation 1.A process in which an organization outside the health care organization, usually non government, assesses the organization to determine if it meets a set of standards designed to improve quality of care .2. The outcome of the review by an accrediting organization. Also, the decision that an eligible organization meets an applicable set of standards.

Accreditation survey an evaluation of organization to assess its compliance with applicable standards and to determine its accreditation status.

 The joint commission international

Accreditation survey includes

* Evaluation of document provided by organization staff that shows compliance;

* Verbal information about the implementation of standards or examples of their implementation that enables compliance to be determined;

* On site observations by surveyors; and

* Education about standards compliance and performance improvement.

Credentialing: the process of obtaining, verifying, and assessing the qualifications of health care practitioner.

Health care organization A generic term used to describe many types of organizations that provide health care services.

Indicator 1. A measure of the performance of functions, systems, or processes over time. 2. A statistical value that indicates the condition or direction of the performance of a process or achievement of an outcome over time. 3. A measurable variable (or characteristic) used to determine the degree to which a standard is met or quality goal is achieved (for example, proportion of nurses who correctly take vital signs on patients admitted to the emergency ward).

Informed consent: The principle that a physician has a duty to inform his or her patients about whatever risks or injury might be incurred from a proposed treatment, test or research. A patient, concerned for his or her own welfare and faced with a choice of undergoing the proposed treatment, test, or research or not may then balance the probable risks against the probable benefits

Leaders Individuals who set expectations, develop plans, and implement procedures. These activities are designed to assess and improve the quality of an organization's government, management, and clinical and support functions and processes. Leaders include the owners, members of the governing body, the chief executive officer and other senior managers, nursing executives and other independent practitioners, as they apply to the organization's structure.

Protocol A plan, or set of steps, to be followed in a study, an investigation, of an intervention.

Risk management Clinical and administrative activities to identify, evaluate, and reduce the risk of injury. This risk could apply to patients, staff, visitors, and the organization itself.

Standard describes the acceptable level of performance of an organization or individual. It relates to structures in place, conduct of a process, or measurable outcome achieved. An expect level of performance that, if attained, would lead to the highest levels of quality in a system. For example, every health provider must wash his or her hands after examining a patient.

The Hospital should prepare the following documents for the survey

* Program Manuals (Operational Policies)

* Hospital Organizational Chart

* Departmental Policies and Procedures

* Medical Staff By –laws, Rules and Regs.

* Medical Records.

* List of Delinquent medical records.

* Hospital Policy of confidentiality.

* Hospital Policy on consent forms.

* Job descriptions.

* Utilization review program document /plan.

* Credentialing files .

* Licensure Verification

* Infection control manual

* Haz met and waste program document

* Risk management and safety manual.

* Personnel records

* Mass casualty and disaster plan.

* Incident reports file.

* Emergency Preparedness plans and drill documentation.

* Preventive Maintenance program document.

* Minutes of executive staff meetings.

* Minutes of committees.

* QM program document and annual plan .

* Standing rules.

* Safety rules.

* Educational Programs and Participation.

* Written agreements.

* Hospital budget.

* Financial audits.

* Laboratory manuals, reports and logs.

* Pharmacy manuals, registries and logs.

* Others,….