Surgery and Endoscopy Ensuring Patient Safety and Compliance ...
Surgery and Endoscopy
Ensuring Patient Safety and Compliance with CMS and
Joint Commission Requirements
Karen Caywood, RN, MBA, CJCP CSR Consultant Joint Commission Resources
? Joint Commission Resources
Objectives
Discuss regulatory requirements for surgery and endoscopy Identify one process to improve patient safety
? Joint Commission Resources
Safety and Compliance
Life Safety Environment of Care Patient Rights (consents and AD) Provision of Care (Assessment, Communication, Orders, Care Plans, Sedation, Anesthesia) Medication Management Record of Care Transplant Safety Human Resources Infection Control Patient Safety (NPSG, Universal Protocol)
3
? Joint Commission Resources
Life Safety
Suite (non-sleeping maximum 10,000 sq ft)
? Suite designations MUST be on LS drawings
Egress obstruction
? May not obstruct egress out of the suite ? If designated as suite, must meet minimum
36 inch clearance - NFPA LSC 7.3.4.1
Block fire pull stations & fire extinguishers
4
? Joint Commission Resources
Environment of Care
Ventilation
Humidity Temperature
? Joint Commission Resources
Who is monitoring? Which rooms or areas are monitored? Documentation?
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