jci newsletter may 8 ipsg

7/27/2019 JCI Newsletter May 8 IPSG

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International Patient Safety Goals (IPSG)*

The purpose of the IPSGs is to promote specific improvements in patient safety. The goals highlight

problematic areas in health care and describe evidence- and expert-based consensus solutions to theseproblems. Recognizing that a sound system design is needed in the delivery of safe, high-quality health

care, the goals encourage organizations to focus on solutions affecting the entire hospital system.

There are six IPSG standards with a combined total of 24 measurable elements (MEs). IPSG.1 has 5 MEs

while IPSG.5 has 3 MEs; the rest have 4 MEs each. Since there are only 24 MEs, a single Partially met

score of 5 shall easily bring down a standards aggregated score to 9.0 or less and the chapters

aggregated score to 9.78 or less. The goal is to score a 10 for each of the 24 measurable elements. As

with other standards, the IPSGs require that the organization has policies and procedures in place to

support the intent of each of these goals.

IPSG.1Identify patients correctly.This standard has a two-fold intent: to reliably identify the individual as the person for whom

the service or treatment is intended, and to match the service or treatment to that individual. Reliable

identification is ensured by using two patient identifiers full name and birthday. Matching the service

or treatment to the correct patient means the patients identification is verified before such treatment

or service is provided including administering medication, blood, or blood products, taking blood or

other specimens for testing, and other treatment or procedures in outpatient services.

What is challenging for TMC: incomplete patient identifiers or use of only 1, wrong patient verification

during initial patient encounter, sticking bar code labels on wrong order sheets.

IPSG.2Improve effective communication.

This standard ensures that communication between health care providers is timely, accurate, complete,

unambiguous and understood by the recipient. Error-prone communication includes patient care orders

or results of critical tests given verbally or through telephone. In such cases, the standards measurable

elements require that: a) the order or test result is written by the receiver, b) the written order or test

result is read back by the receiver to the giver, and c) the order or test result is confirmed by the

individual who gave it.

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What is challenging for TMC: documenting that read-back did occur.

IPSG.3 Improve the safety of high-alert medications.

High-alert medications are those with high risk for errors and/or sentinel events and adverse

outcomes. High-alert medications also include look-alike/sound-alike drugs. The organization should

collaboratively develop its policies and procedures wherein it identifies its own list of high-alert

medications based on its own data, and identifies how they will be labeled and stored in such a way thatinadvertent administration is prevented. In areas where storage of high-risk medications is allowed,

these should be labeled clearly and that they are stored in such a way that access is restricted.

Whats challenging for TMC: concentrated electrolytes can still be found in areas where they should not

be.

IPSG.4Ensure correct-sight, correct-procedure, correct-patient surgery.

Surgeries involving wrong patients, wrong body sites or wrong procedures do happen as a result

of ineffective or inadequate communication between members of the surgical team. This IPSG standard

ensures that the Universal Protocol s implemented in all applicable areas of the hospital. The standard

also calls for policies and procedures governing the implementation and monitoring of the Universal

Protocol in settings other than the OR where medical and dental procedures are done.

Whats challenging for TMC: documentation that time out do occur, Universal Protocol in applicable out-

patient areas.

IPSG.5 Reduce the risk of health care-associated infections

Proper hand hygiene is an intervention recommended by the World Health Organization and the

US Centers for Disease Control and Prevention to prevent common health care-associated infections

(HCAIs). The organization has to demonstrate that it has adapted the recommended guidelines and that

it effectively implements its hand hygiene program through 100% compliance. This standard also makes

sure that policies and procedures for continued reduction of HCAIs are in place and are being followed

by the entire organization.Whats challenging for TMC: non-compliance to moments 1 and/or 5, absence of hand-rub dispensers in

certain areas

IPSG.6 Reduce the risk of patient harm resulting from falls

This standard ensures that the organization should evaluate its patients risk for falls and take

action to reduce the risk of falling and to reduce the risk of injury should a fall occur. The organization

should establish a fall-risk reduction program based on appropriate policies and procedures.

Whats challenging for TMC: correct initial assessment and re-assessment, appropriate interventions

based on assessment.

*Taken from JCI Accreditation Standards for Hospitals, 4th

edition, pp.35-40

JCIA Newsletter

JCIA Newsletter 2012

Lead Editor: Dianne AchasContributors:

Jose M. Acuin, M.D.

Beth Vargas

James Cayabyab

Precious Aruelo

Michelle Casuga

Jen De Dios


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Ways to Ace the IPSG Standard

The JCI International Patient Safety Goals (IPSG) form

the bedrock of patient safety. Their achievement is

critical to full compliance with the JCI standards.

Because the 6 IPSGs form a separate standards

chapter, they greatly impact on the total survey score

of Medical City. In addition, the QPS standards requirethat a monitoring tool is used to track compliance to

each of the 6 IPSGs. This issue of the JCI Newsletter is

devoted to the JCI IPSGs and their intent statements.

The applicability grid that follows the text shows the

different areas in the hospital where the 6 IPSGs must

be achieved.

Goal 1: Identify Patients Correctly (IPSG.1)

The organization develops an approach to improve

accuracy of patient identifications.

Before giving medications, blood, or blood products;taking blood or other specimens for clinical testing; or

providing any other treatments or procedures, tell the

patient, Can you please tell me your full name and

birth date? I need to confirm it before I perform this

procedure on you.

Goal 2: Improve Effective Communication (IPSG.2)

The organization develops an approach to improve the

effectiveness of communication among caregivers.

Do not text criticalinformation such as assessment

findings and orders. You will never be sure you have

been completely understood or that the person you aretexting is going to act on the critical information

promptly and appropriately. If you must text critical

information, make a follow-up call to confirm

understanding and effective response to your concerns.

When transmitting critical information such as orders

or test results verbally OR over the phone, make sure

the recipient of your information writes it down

completely and legibly (or enters into a computer),

reads back the information to you and confirms with

you that what has been written down and read back is

accurate.

Remember: You have effectively communicated to

someone only after you are sure you have been

understood.

Goal 3: Improve the Safety of high-Alert Medications

(IPSG.3)

The organization develops an approach to improve the

safety of high-alert medications.

Check if your unit or department uses any of themedications included in the DrugWatch list.

Place warning labels such as Drug Watch List, Look-

Alike and Sound-Alike, etc. in the medicine bins. Use

Tallman labeling to prevent errors in look-alike and

sound-alike drugs. For drugs with sound-alike names,

the generic and brand names shall be written together

with the indication in order to verify drug identity.

Illegible, unclear or incomplete orders shall be verified

with the Prescribing Doctor prior to transcription.

Use standardized drip whenever possible

Use premixed solutions unless otherwise indicated(e.g., concentrated dopamine solutions for congestive

heart failure).

Telephone and verbal orders are strictly not allowed

except for IV follow-up, provided the physician will

write and/or countersign the order within 30 minutes.

The NIC must verify the illegible and unclear drug

orders through the read back process. Orders given by

the physician should be read back by the nurse-in-

charge to ensure proper understanding. In the absence

of the NIC, the physician should expect a call from the

unit regarding his/her order for clarification.

The staff pharmacist will not accept any verbal orders

to prepare incorporations of intravenous electrolytes.

The intravenous admixture of electrolytes and

chemotherapeutic agents will only be prepared by the

staff pharmacist upon receipt of the Physicians Order

Sheet (POS) and the corresponding charge slips for the

request. For incorporations of electrolytes to present

intravenous infusions, the staff pharmacist will prepare

the quantity of electrolytes to be added to the

intravenous infusion upon receipt of the POS and the

corresponding charge slip for the request.

Pharmacists compound and dispense sodium chloride

solutions above 9% (Therapeutics)

Dilution and infusion rates are prepared and set by

nurse-in-charge as ordered by the attending physician

and counter-checked by head nurse prior to

administration. (Therapeutics)

Use infusion pumps for infusion of chemotherapy and

other medication requiring accurate and timely

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regulation such as aminophyline, heparin, insulin,

inotropics and electrolytes and for critically-ill patients.

(NSD manual)

Goal 4: Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery (IPSG.4)

The organization develops an approach to ensuring

correct-site, correct-procedure, and correct-patient

surgery.

1. The correct operation and site of theoperation should be specified when the

procedure is scheduled, should be noted on

the record of the history and physical

examination and should be specified on the

informed consent. Anyone reviewing the

schedule, consent, history and physical

examination, or reports documenting the

diagnosis, should check for discrepancies

among all those parts of the patients record

and reconcile any discrepancies with the

surgeon when noted.2. All information that should be used tosupport the correct patient, operation, and

site, including the patients or familys verbal

understanding, should be verified by the

nurse and surgeon before the patient enters

the OR. Any discrepancies in the information

should be resolved by the surgeon, based on

primary sources of information, before the

patient enters the OR.

3. All verbal verification should be done usingquestions that require an active response of

specific information, rather than a passive

agreement.

4. The site should be marked by a healthcareprofessional familiar with the facilitys

marking policy, with the accuracy confirmed

both by all the relevant information and by an

alert patient or patient surrogate if the patient

is a minor or mentally incapacitated. The site

should be marked by the providers initials.

The site mark should be visible and referenced

in the prepped and draped field during the

time-out.

5. All information that should be used to supportthe correct patient, operation, and site,

including the patients or familys verbal

understanding, should be verified by the

circulating nurse upon taking the patient to

the OR.

6. Separate formal time-outs should be done forseparate procedures, including anesthetic

blocks, with the person performing that

procedure.

7. All noncritical activities should stop during thetime-out.

8. Verification of information during the time-out should require an active communication

of specific information, rather than a passive

agreement, and be verified against the

relevant documents. All members of the

operating team should verbally verify that

their understanding matches the information

in the relevant documents.

9. The surgeon should specifically encourageoperating team members to speak up if

concerned during the time-out. Operatingteam members who have concerns should not

agree to the information given in the time-out

if their concerns have not been addressed.

Any concerns should be resolved by the

surgeon, based on primary sources of

information, to the satisfaction of all members

of the operating team before proceeding.

Goal 5: Reduce the Risk of Health CareAssociated

Infections (IPSG.5)

The organization develops an approach to reduce the

risk of health careassociated infections.Habit Always wash in and wash out upon

entering/exiting a patient care area and before and

after patient care

Make washing hands a habit as automatic as

looking both ways when you cross the street or

fastening your seat belt when you get in your car

Active Feedback Coach and intervene to remind staff to wash

hands. Provide real time performance feedback

Clearly state expectations about when to sanitize

hands to all staff members

Communicate frequently provide visiblereminders and ongoing coaching to reinforce

effective hand hygiene expectations

Celebrate improved hand hygiene

No One Excused Protect the patient and the environment

everyone must wash in and wash out

Make it comfortable to wash hands with soap or

use waterless hand sanitizer

Hold everyone accountable and responsible

doctors, nurses, food service staff, housekeepers,

chaplains, technicians, therapists

Apply progressive discipline from the top

managers must hold everyone accountable forproper hand washing

Commit to achieve hand hygiene compliance of

90+ percent

Serve as a role model by practicing proper hand

hygiene Make it easy; examine work flow of

health care workers to ensure ease of washing

hands:

Provide easy access of hand hygiene equipment

and dispensers

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Create a place for everything: for example, a health care worker with full hands needs a dedicated space wherehe or she can place items while washing hands

Limit entries and exits from a patients room make supplies available in room and eliminate false alarms that

require staff to leave room to turn alarm off

Goal 6: Reduce the Risk of Patient Harm Resulting from Falls (IPSG.6)

The organization develops an approach to reduce the risk of patient harm resulting from falls.Review medications, especially high- risk medications, such as sedatives, antidepressants, antipsychotics and

centrally acting pain relief.

Assess and manage bone health in older people who have, or who are at risk of, low-trauma fractures. This

includes the use of vitamin D and calcium, as well as formal treatments for osteoporosis.

Check lying and standing blood pressure in older patients at risk of falls.

Ensure that acutely confused patients are investigated for the cause of the delirium, and contribute to the

clinical management plan for managing confused older patients.

Avoid using physical or chemical restraints, where possible.

If a patient falls while in hospital, examine them and investigate the fall as needed. Assess the patients risk of

falling in future, and provide individualized interventions to minimize this risk.

Ensure that older patients have their usual spectacles and visual aids in hand.

Organize routine screening urinalysis to identify urinary tract infection.

Organize routine physiotherapy review for patients with mobility difficulties:

Communicate to staff and the patient the limits of the patients mobility status using written, verbal and visual

communication

Put walking aids on the side of the bed that the patient prefers to get up from, and, where possible, assign a

bed that allows them to get up from their preferred side

Supervise or help the patient if required

Make sure that, while mobilizing, the patient wears fitted, nonslip footwear (discourage the patient from

moving about in socks, surgical stockings or slippers)

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TMC iNSTYLE

the Project JCi Wear T-shirt Design Competition and Fashion Show

Last May 3, 2012, the TMC community feasted their eyes on one of a kind fusion of fun, beauty, creativityand fashion as carefully selected models from various departments strut their way on the fashion ramp for

the first ever Project JCi Wear Fashion Show. The show is the first of the many events that the Medical

Quality Improvement Office and its partner departments have planned and organized this year in

preparation for the JCI re-accreditation in November.

As early as the day before, our Facilities and Housekeeping staff were seen constructing and decorating thespecially-designed catwalk at the Foyer where the event was held. Blue and yellow balloons, life-size

standees of the models, and multi-colored lights adorned the venue. Staff, patients and visitors alike felt the

excitement as soon as the upbeat music signaled the start of the show. The audience swelled shortly

thereafter upon seeing the events celebrity hosts, Maverick Only (of Totoo TV fame) and CRDs Ella

Lacson. Four departments gamely participated and expressed their support and commitment to JCIA by

designing artistically crafted T-shirts modeled by their own staff. These departments were Admissions,

Cathlab, Medical Information, and Systems and Quality. The Admitting Department bagged all the major

prizes including the Best T-shirt design (by Ms. Lourdes Zabala) and the Best Male and Female Models

(Vermont Ventura and Lou Angielyn Cruz). The winning design shall be used as inspiration for the 2012 TMC

Whats out for JCi Rock: TMCno sikat?!

Calling all TMC bands! Join our rock band contest at ipakitana kayo ang sikat!If your band has 5-7 members, you qualify.We will provide the lyrics, you provide the music. Submityour demo recording and be ready to perform your songduring the JCi Rock event in July. Amazing, amazing prizesare in store!

Interested parties may inquire at MQIO or CHI. Posters andannouncements will be released very, very soon.

JCi wear female models. L-R: Jean (MID), Lou(Admissions); Mich (Cathlab); & Cathy (SQD)

JCi Wear First Place Winners, Lourdes Zabala and

models Vermont Vergara & Lou Angielyn Cruz

receiving their award from Ms. Margaret

Bengzon and Dr. Jose Acuin,

JCi Wear Hosts:

Mr. Maverick Only

& Ms. Ella Lacson.

JCi wear male models. L-R: Jonathan (MID),

Vermont (Admissions); Ram (Cathlab); &

Chester (SQD)

Question No. 1

In what 2 stand

did TMC obtai

perfect 10 in 2

Survey?

Question No. 2

What are the

names of the 3 J

surveyors who

visited TMC las

2009?

jci newsletter may 8 ipsg

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