Loyola University Health SystemMission StatementLoyola University Health System iscommitted to excellence in patient careand the education of health professionals.We believe that our Catholic heritageand Jesuit traditions of ethical behavior,academic distinction, and scientificresearch lead to new knowledge andadvance our healing mission in thecommunities we serve. We believethat thoughtful stewardship, learningand constant reflection on experienceimprove all we do as we strive to providethe highest quality healthcare.We believe in God’s presence in allour work. Through our care, concern,respect and cooperation, we demonstratethis belief to our patients and families,our students and each other. To fulfillour mission we foster an environmentthat encourages innovation, embracesdiversity, respects life and values humandignity. We are committed to goingbeyond the treatment of disease. We alsotreat the human spirit.Trinity Health Mission StatementWe, Trinity Health, serve together in thespirit of the Gospel as a compassionateand transforming healing presence withinour communities.Core ValuesReverenceWe honor the sacredness and dignity ofevery person.Commitment to Those Who are PoorWe stand with and serve those who arepoor, especially those most vulnerable.JusticeWe foster right relationships to promotethe common good, including sustainabilityof Earth.StewardshipWe honor our heritage and hold ourselvesaccountable for the human, financial andnatural resources entrusted to our care.IntegrityWe are faithful to who we say we are.

Joint CommissionReadiness GuidebookINTRODUCTION AND PURPOSE . . . . . . . . . . 2PATIENT RIGHTS AND CONFIDENTIALITY . . . . . 4QUALITY AND PATIENT SAFETY . . . . . . . . . . . 6NATIONAL PATIENT SAFETY GOALS . . . . . . . . . 8SERVICE EXCELLENCE . . . . . . . . . . . . . . . 12ENVIRONMENTAL HEALTH & SAFETY . . . . . . . 14Emergency Codes . . . . . . . . . . . . . . . . . . 14Fire Safety . . . . . . . . . . . . . . . . . . . . . . 15Hazardous Materials . . . . . . . . . . . . . . . . . 16Suicidal Ideation or PsychiatricallyCertified Patients . . . . . . . . . . . . . . . . . . . 18Emergency Management . . . . . . . . . . . . . . 19INFECTION CONTROL . . . . . . . . . . . . . . . . 20Pain Management Process . . . . . . . . . . . . .20Restraints . . . . . . . . . . . . . . . . . . . . . . . 21Interdisciplinary Plan Of Care (IPOC) . . . . . . . . 21Patient/Family Education . . . . . . . . . . . . . .21

INTRODUCTION AND PURPOSEThe Joint Commission JourneyLike most healthcare providers, LoyolaUniversity Health System (LUHS)is routinely evaluated to ensure itcontinues to provide safe high-qualitycare to patients. The Joint Commission(TJC) conducts surveys to assess ourcompliance with standards of patientcare. Please take the time to prepare forTJC’s visit so we can share our pride inwhat we do.What is The Joint Commission?TJC is an organization dedicated toimproving the quality of care in healthcaresettings. Its major functions includedeveloping organizational standards andperformance measurement, awardingaccreditation and certification andproviding education and consultation.When will the survey occur?TJC surveys are unannounced and canoccur anytime. LUHS will receive noticeat 7:30 am on the first day of the survey.The TJC Command Center will open andget the word out to everyone, includingspecial pages to management, computeralerts, overhead announcements in thehospital, flat-screen announcements andbroadcast voicemails and emails. Thesurvey team will arrive by 8 am. Surveyorswill focus on inpatient care, ambulatoryand home medical equipment standards.The surveyors will also conduct life safetytours for the entire main campus.2Survey TipsBefore the surveyor arrives Know what to expect – review allpreparation materials and knowwhere to find the answers. Read the monthly PatientSafety Readiness newsletter.How can I stay ready and informedabout the TJC survey? Ask your manager and participatein preparation activities in yourdepartment. Watch for information on flat-screenannouncements, posters and badges. Know how to access policies andpatient education materials on theintranet. Check the LUHS Patient SafetyReadiness Website. Go to Spirit, clickon Resources and scroll down to JointCommission Readiness. .aspx

INTRODUCTION AND PURPOSESurvey TipsThroughout the week, the surveyorswill do patient tracers. After selectinga specific patient, the surveyor willgo to different patient care areas,test and treatment areas and supportdepartments that have participated inthe care and services for that patient.When the surveyor arrives Look and behave professionally. Be very attentive to yourenvironment. Try to make itas neat, orderly, clean andorganized as possible. Clear hallways and stairwells ofany equipment or carts (isolation,chemotherapy and crash cartsmay remain in the hall).When the surveyor asks youa question Be enthusiastic and friendly. Relaxand take a deep breath. Be sure youunderstand the question. After givingit some thought, answer the question.If you don’t know the answer, tellthe surveyor where you can find theanswer or who can help provide it. Stoptalking once you have answered thequestion. Surveyors aren’t looking fora LONG answer – they are looking forthe RIGHT answer.Work as a team. Volunteer to helpyour co-workers by helping to answera question OR offer to cover for theirresponsibilities while they are speakingwith the surveyor. Use your life-lines.Ask your manager or check intranetresources. Refer to information in thisguidebook and on your National PatientSafety Goal badge and EmployeeSafety Information badge.3

PATIENT RIGHTS, CONFIDENTIALITY AND PRIVACYHow does LUHS protect patients’rights?Relationships between the patient, familyand hospital staff are based on trust andmutual respect. LUHS protects the rightsof patients by: Planning care to meet their needs Making sure they understand plansfor their care Involving patients and their familiesin decisions regarding their treatment Clearly explaining authorization andconsent forms Providing patients with informationabout advance directives, such as livingwills and assigning power of attorney Providing interpreters whencommunication barriers exist4 Upholding patients’ rights to refusetreatment as long as it is not againstthe law Respecting patients’ rights to changedoctors or hospitals Ensuring they receive prompt andeffective relief for painHow do we protect patients’ privacyand confidentiality?We guard the privacy and confidentialityof patients by: Following HIPAA guidelines beforereleasing patient information Making sure only authorized personsreview patients’ records Not talking about patients in elevatorsor other public areas

PATIENT RIGHTS, CONFIDENTIALITY AND PRIVACY Logging off computer screensand guarding folders that containconfidential patient information Knocking on the patient’s door beforeentering and pulling privacy curtainsonce in the room Allowing computer access througha password system Shutting doors when an exam or testis being done Giving treatments and examiningpatients in private Disposing of patients’ papers andreports in designated containers orshredding them Asking the patient’s permissionbefore discussing their care in frontof visitors or other patientsSurvey TipsFor the full listing of how LUHS upholds patients’ rights and confidentiality, checkthe Patient’s Bill of Rights posted in the lobbies of all buildings as well as in theonline policy, LUMC: Patient Rights and Responsibilities/GMH: Patient Rightsand Responsibilities and Patient Guide.5

QUALITY & PATIENT SAFETY AT LUHSWhat approach does LUHS use toimprove quality?Quality project planning begins with threequestions:1. Project Aim & Goal – What are wetrying to accomplish?2. Measurement – What will we countto be sure that changes we makeare an improvement?3. Solutions – What changes can wemake?Changes are then tested using multiplePLAN-DO-STUDY-ACT cyclesPLAN: Plan the testDO: Test the change and collect dataSTUDY: Analyze the data and developconclusionsACT: Make a decision to adopt thechange, revise it or stop it. Beginanother cycle.LEAN/Six Sigma TransformationLUHS also uses LEAN/Six-Sigmaprinciples (DMAIC), to help improveprocesses and create efficiencieswithin our departments and across thesystem. Regular kaizen events are heldin targeted areas to assess the currentstate, brainstorm potential changes, tryout process changes and “go-live” withnew processes.What is LUHS doing to improve thequality and safety of patient care?System-wide quality improvement teamshave improved processes for: Reduction of central-line bloodstreaminfections, catheter-associated urinarytract infections and post-op venousthrombus embolus Reducing readmissions to the hospital Reduction of patient falls andpressure ulcers Reducing mortality due to severesepsis/septic shock6

QUALITY & PATIENT SAFETY AT LUHSThe Joint Commission’s Core Measuresfocus on the clinical care for specificpatient populations. These includeinfluenza immunization, stroke, venousthromboembolism (VTE), sepsis,perinatal measures, emergencydepartment measures and outpatientmeasures. Our compliance with theseevidence-based measures is availableto the public on the internet.What initiatives is LUHS workingon to improve patient safety? Patient Safety Hotline: available forstaff, patients and families to reportconcerns about safety: Patient safety videos on the flat-screenmonitors used throughout the system Unit/department based Patient SafetyRisk AssessmentsAND Implementation of National PatientSafety GoalsStaff InteractionQuality & Patient Safety:The quality and patient safety activitiesthat my department is working on are: LUMC: 708-327-SAFE G MH Patient Relations:708-538-4103 System-wide patient safety educationfor all physicians and staff Follow-up on trends of adverseevents and near misses reportedvia the online patient safetycommunication system Root cause analysis of events andfailure mode effects analysis toanalyze new and existing processesfor potential problems7

NATIONAL PATIENT SAFETY GOALSThe Right Patient Use TWO patient identifiers (Name andDate of Birth) every time you administermedications and blood, obtain blood andlab samples and do procedures. Labelblood and lab samples at the bedside orchair in the presence of the patient. efore administering a blood transfusion,Bidentify the patient using a two-personverification process at the bedside orchair. Include the patient in this process. ll components of the Universal ProtocolAmust be documented. Confirm the correctPATIENT, SITE and PROCEDURE ateach step. A pre-procedure verification processis required to confirm that therequired documentation, equipmentand supplies are available. Verify thecorrect patient, site and procedurewhen the procedure is scheduled,during pre-admission testing, on theprocedure day and when the patient ismoved from the pre-procedure setting8 The MD marks the surgical siteBEFORE all procedures when there ismore than one possible location for theprocedure. Actively involve the patientin the process Conduct a time-out prior to allsurgeries and invasive procedures,actively involving all team membersto address the following: Correct patient – check nameand date of birth Correct site – marked and visible orrect procedure – matchesCthe consentEffective Communication Report, read back and document allcritical test results immediately.

NATIONAL PATIENT SAFETY GOALSSafe Medication Use Label all medications and solutions,including water and saline, on and offthe sterile field.and the potential for adverse drugreactions and interactions. Documentthe teaching in the Epic PatientEducation ModuleLabeling should include:Reconcile medications. Drug name, strength, amount ofmedication or solution containingmedication, diluents name and volume1. On admission, document the patient’scomplete home medication list in Epic.Review dose, route and frequency foraccuracy of each medication. Expiration date when not used within24 hours Expiration time when expiration occursin less than 24 hours se standard protocols (Epic order sets)Uto initiate and maintain anticoagulationtherapy: Use oral unit-dose oral meds, pre-filledsyringes, or pre-mixed infusion bags.Administer heparin via programmablepump2. When a new medication is ordered,compare against the list of currentmedications. Reconcile and documentany discrepancies.3. Reconcile/check/documentmedication list at all patient transfersand at discharge. Provide updatedmedication list to the patient/familyand the next provider at discharge. Monitor labs regularly - obtain baselineand daily INR for all patients onwarfarin therapy Educate patients and families on theimportance of follow-up monitoring,compliance, food-drug interactions9

NATIONAL PATIENT SAFETY GOALSPrevent Infections Perform hand hygiene with antiseptichand gel or with soap and water for atleast 15 seconds before and after anypatient encounter. Use soap and waterif visibly soiled or when caring for apatient with Clostridium difficile (C. diff). Prevent infections from multiple-drugresistant organisms (MRSA, VRE,gram-negative bacteria and C. diff).– Wash your hands and useappropriate PPE – gloves,masks, gowns.– Strictly follow isolationprecautions guidelines. Prevent central line/PICC lineinfections by following protocolsfor line insertion and maintenance.– Insertion: Use insertion bundlechecklist, standardized supplykit, maximum sterile barrier andchlorhexidine antiseptic for skin prep,apply Biopatch disk