JCI第四版教学讲解课件

InternationalPatientSafetyGoals(IPSG)

1ImprovingPatientSafety

means...ReducingMedicalErrorsReducingPatientHarmChallengesforPatientSafetyLeadership

Movetowardamoresafety-orientedculturePracticeproactivesystemsanalysis&riskreductionStandardizeprocessesandequipmentPromoteeffectivecommunicationEnsureadequateandeffectivestaffingImplementteamtrainingforallstaffEncourageandsupportpatientinvolvementSystemsAnalysisinHealthCare

Asystematicevaluationofahealthcareorganization’ssystemsandprocesses:

Toidentifyvulnerabilitiesandhazardousconditionsthatcould(and,overtime,will)impactpatientsafetyandqualityofcare.Tofocustheredesignofthosesystemsandprocessestoimprovepatientsafetyandqualityofcare.ImplementationofIPSG….RepresentsproactivestrategiestoreduceriskofmedicalerrorandreflectgoodpracticesproposedbyleadingpatientsafetyexpertsIncorporatingthesenewtoolsintoouraccreditationrequirementsisasignificantstepOrganizationstakingresponsibilityforusingtheIPSGtofosteranatmosphereofcontinuousimprovementisevenmoreimportantJCI4thEditionInternationalPatientSafetyGoalsPSG1 IdentifyPatientsCorrectlyPSG2 ImproveEffectiveCommunicationPSG3 ImprovetheSafetyofHigh-AlertMedicationsPSG4 EnsureCorrect-Site,Correct-Procedure,Correct-PatientSurgeryPSG5 ReducetheRiskofHealthCareAssociatedInfectionsPSG6 ReducetheRiskofPatientHarmResultingfromFallsIPSG.1

IdentifyPatientsCorrectlyAcollaborativeprocessisusedtodeveloppoliciesand/orproceduresthataddresstheaccuracyofpatientidentification

Useatleasttwo(2)waystoidentifyapatient:givingmedicationsgivingbloodandbloodproductstakingbloodsamplestakingothersamplesforclinicaltestingprovidingtreatmentorprocedureThepatient’sRoomNumbercannotbeusedasanidentifier

ThecompleteVOandTOortestresultiswrittendownbythereceiveroftheorderortestresult.Mustuseaverification“readback”ofcompleteorderortestresultTheorderortestresultisconfirmedbytheindividualwhogavetheorderortestresultPoliciesandproceduressupportconsistentpracticeverifyingtheaccuracyofverbalandtelephonecommunicationsIPSG2:ImproveEffectiveCommunicationPolicies/proceduresaredevelopedtoaddressidentification,location,labelingandstorageofhigh-alertmedicationsPolicies/proceduresareimplementedConcentratedelectrolytesarenotpresentinpatientcareunitsunlessclinicallynecessaryandactionsaretakentopreventinadvertentadministrationConcentratedelectrolytesthatarestoredinpatientcareunitsareclearlylabeledandstoredinamannerthatrestrictsaccessIPSG3:ImproveSafetyofHighAlertMedicationsClinicalNecessityHastobesupportedbyevidenceIsthesubstancereallyneededveryquickly?Ifitisusedtodilute,isthedilutedsolutionavailable?IPSG4:EnsureCorrect-site,Correct-procedure,Correct-patientSurgeryCollaborativelydevelopapolicy/procedurethatincludes:Definitionofsurgerythatincorporatesatleastthoseproceduresthatinvestigateand/ortreatdiseasesanddisordersofthehumanbodythroughcuttingremoving,altering,orinsertionofdiagnostic/therapeuticscopes.IPSG4CorrectSite,ProcedureandPatient

UseaninstantlyrecognizablemarkforsurgicalsiteidentificationInvolvesthepatientinthemarkingprocessInvolvesthefullsurgicalteamandisdocumentedjustbeforestartingasurgicalprocedurePolicies/proceduresaredevelopedtosupportuniformprocesstoensurecorrectsite,procedure,andpatient(includingmedicalanddentalproceduresdoneinsettingsotherthantheoperatingtheater)Checklistorotherprocesstoverify:CORRECTSURGERYSITEDOCUMENTSEQUIPMENTFunctional&CorrectPROCEDUREPATIENTPSG5:ReducetheRiskofHealthCare-AssociatedInfectionsNeeddatatodemonstrateeffectivenessTheorganizationhasadoptedoradaptedcurrentlypublishedandgenerallyacceptedhand-hygieneguidelinesImplementsaneffectivehand-hygieneprogramPolicies/proceduresaredevelopedthatsupportcontinuedreductionofhealthcareassociatedinfectionsIPSG6:ReducetheRiskofPatientHarmresultingfromFallsImplementsaprocessfortheinitialassessmentofpatientforfallriskandreassessmentofpatientswhenindicatedbyachangeinconditionormedications,amongothersMeasuresareimplementedtoreducefallsriskforthoseatriskIPSG6ReducingRiskofHarmResultingfromFallsMeasuresaremonitoredforresults,bothsuccessfulfallinjuryreductionandanyunintentionalrelatedconsequencesPolicies/proceduressupportcontinuedreductionofriskofpatientharmresultingfromfallsintheorganizationThankYouNextPresentationAccesstoCareand

ContinuityofCare(ACC)18ACC-FiveAreasofFocusAdmissiontotheOrganizationContinuityofCareDischarge,Referral,andFollow-upTransferofPatientsTransportationACC.1“ADMISSION”ofIn-Patients&“REGISTRATION”ofOut-PatientsScreeningatpointoffirstcontactDetermineifcarecanbeprovidedDiagnostictestareavailablefordecisionmaking-standardizedbypolicyPatientsareinformedifanywaitordelayandreasons(waitinglist)ACC.1.1ProcessofAdmissionorRegistrationPolicies&Procedures(PP)standardizeadmissionandregistrationforout-patientsandin-patientsPPAdmittingemergencypatientsPPHoldingpatientsforobservationPPManagingpatientswhenbedspacenotavailableACC.1.1.1EmergencyPatientsEvidencebasedtriageprocessisusedtoprioritizepatientswithimmediateneedsStaffaretraineduseofthetriageprocessStaffprioritizepatientsbasedonurgencyofneedsEmergencypatientsareassessedandstabilizedpriortotransferACC.1.1.2NeedsarePrioritized

forIn-patientsScreeningassessmentidentifiespatient’sneedsServicesorunitsareselectedtomeetneedsbasedontheassessment:–Preventative–Palliative–Curative–RehabilitativeACC.1.1.3WaitingPeriodsorDelays

In-patientsandout-patientsareinformedofdelaysReasonfordelayandavailablealternativesDocumentedinthepatientmedicalrecordWrittenpolicies/proceduresACC.1.2InformationProvidedPatientandFamilyreceiveinformationduringtheadmissionprocesson:ProposedcareExpectedoutcomesofcareExpectedcostsSufficientinformationtomakeknowledgeabledecisionsACC.1.3ReductionofBarriersLeadersandstaff

identifymostcommonbarriersforpatientsPhysicalLanguageCulturalOtherAprocessisidentifiedandimplementedtoovercomeorlimitidentifiedbarrierstolimitimpactofbarriersondeliveryofservicesACC.1.4CriteriaforAdmissionorTransfertoIntensiveCareAdmission/transfercriteriaestablishedforIntensiveandSpecializedUnitsCriteriaarephysiologic-basedAppropriateindividualsareinvolvedindevelopingandimplementingthecriteriaPatientsmeetthecriteria(documented)Patientsaredischarged/transferredwhentheynolongermeetcriteriaACC.2ContinuityofPatientCare

Leadersdesignandsupportcontinuity(coordination&resources)CriteriaorpoliciesdeterminetransferswithintheorganizationContinuityandcoordinationisevidentthroughoutallphasesofpatientcareandtothepatientACC.2.1IndividualResponsibleThereisanindividualresponsibleforpatient’scarewhois

aphysicianorotherpersonqualifiedtoassumeresponsibilityforcareidentifiedtothehospitalstaffTheindividualdocumentsthepatientplanofcareTransferfromoneindividualtoanotherisdescribedinpolicyACC.3ReferralandDischargePolicyPolicyfortheappropriatereferralordischargeofpatientsBasedonpatient’sneedsforcontinuingcareThepatient’sreadinessfordischargeDischargeplanningbeginsearlyandincludesthefamilyasappropriatePolicyguidespatients“onpass”foradefinedperiodoftimeACC.3.1CooperationwithCommunityPractitioners

Dischargeplanningforbothsupportive

andcontinuingmedicalservicesCommunityproviders,organizationsandindividualsareidentifiedAppropriatereferralsaremade(inthepatient’shomecommunitywheneverpossible)ACC.3.2DischargeSummaryIn-patientclinicalrecordscontainadischargesummarypreparedbyaqualifiedindividualFollowupinstructionsCopiesare:Inthepatient’smedicalrecordGiventothepatientatdischargeProvidedtopractitionerresponsibleforcontinuedcarePolicyandproceduredefinedischargesummaryACC.3.2.1DischargeSummaryPreparedatdischarge,documentedinthepatient’srecordandcontains:ReasonforadmissionSignificantphysicalandotherfindingsSignificantdiagnosesandco-morbiditiesDiagnosticandtherapeuticproceduresSignificantmedicationandtreatmentsConditionatdischargeDischargemedicationsandallmedicationstobetakenathomeFollowupinstructionsContinuedonnextslide…..ACC.3.2DischargeSummaryUnlesscontrarytopolicy,laws,orculture,patientsaregivenacopyAcopyisprovidedtothepractitionerresponsibleforpatient’scontinuingorfollow-upcareACC.3.3OutPatientSummaryofContinuingCareIdentifywhichcontinuingcarepatientsrequireasummaryIdentifyhowthesummaryismaintainedandwhomaintainsitIdentifyformatandcontentofsummaryDefinewhatisconsideredcurrentPolicyforcompletedsummaryACC.3.4UnderstandableFollowUpInstructionsFollowupinstructionsareunderstandableReturnforfollowupcareWhentoobtainurgentcareCarenecessarytopatient’sconditionACC.3.5AgainstMedicalAdviceProcessformanagementandfollowupofin-patientsandoutpatientswholeaveAMAKnownfamilyphysiciansarenotifiedApplicablewithlocallawsandregualtionsACC.4TransferPolicyGuidingprocessfortransferringpatientstoinclude:Patient’sneedforcontinuingcareTransferofresponsibilitytoanotherproviderorsettingWhoisresponsibleduringtransferSituationswheretransferisnotpossibleACC.4.1ReferringandReceivingOrganizationsReferringorganizationdetermineswhetherreceivingorganizationcanmeetpatient’sneedsArrangements(formalorinformal)areinplacewhenpatientsarefrequentlytransferredACC.4.2WrittenSummaryClinicalsummaryistransferredwithpatient&includes:PatientstatusProceduresOtherinterventionsprovidedPatient’scontinuingcareneedsACC.4.3MonitoringPatientsDuringTransferAllpatientsaremonitoredduringdirecttransferQualificationsofthestaffmemberdoingthemonitoringareappropriateforpatient’sconditionACC.4.4DocumentationofTransferDocumentationincludes:NameoforganizationandindividualagreeingtoreceivepatientReasonfortransferAnyspecialconditionsrelatedtotransferAnychangeofpatient’sconditionorstatusduringtransferAnyothernotesrequirebythetransferringorganizationACC.5PlanningTransportationNeedsAssessmentoftransportationneedswhenreferringpatientsTransportationisarrangedappropriatetopatientneedsOwnedtransportvehiclesmeetlawsandregulationsContractedtransportationmeetspatientneedsAppropriateequipmentMonitoringthequalityandsafetyortransportationIncludesacomplaintprocessThankYouNextPresentationPatientandFamilyRights(PFR)45PFR–SixAreasofFocusIdentify,ProtectandPromotePatientRightsInformPatientsofTheirRightsIncludingPatient’sFamilyinDecisionsInformedConsentResearchOrganDonationPFR.1ProcessesSupportRightsLeadersworkcollaborativelytoprotectandadvancepatientandfamilyrightsunderstandrightsasdefinedinlawsandregulationsStaffmembersareknowledgeableandcanexplaintheirresponsibilitiesPoliciesandProcedures(PP)guideandsupportpatientandfamilyrightsContinuedonnextslidePFR.1ProcessSupportRightsThehospitalrespectspatientrights,andinsomecasestherightsofpatient’sfamily:tohavetheprerogative

todeterminewhatinformationisprovidedthefamilyandothers,andunderwhatcircumstances.PFR.1.1Patient’sValuesandBeliefsThereisahospitalprocesstoidentifyandtorespectpatientvaluesandbeliefsandthoseofthefamilyStaffmembersusetheprocessprovidecarerespectfulofthepatient’svaluesandbeliefsPFR.1.1.1SpiritualSupportThereisaprocesstorespondtorequestsforreligiousorspiritualsupportProcessisdesignedtoaccommodate:RoutinerequestsComplexrequestsPFR.1.2PatientPrivacyStaffmembersidentifypatientexpectationsandneedsforprivacyThepatient’sexpressedneedforprivacyisrespectedinall:ClinicalinterviewsExaminationsProcedures/treatmentsTransportPFR.1.3PatientPossessionsThehospitaldefinestowhatextentitisresponsibleforpatient’spossessionsPatientsareinformedofthehospital’sresponsibilityPatient’spossessionsaresafeguardedwhenthehospitalassumesresponsibilityorwhenthepatientisunabletoassumeresponsibilityPFR.1.4PhysicalAssaultThereisaprocesstoprotectpatientsfromassaultThoseaddressedintheprocessare:Infants,Vulnerablechildren,ElderlyOthersunabletoprotectthemselvesIndividualswithoutidentificationareinvestigatedRemoteorisolatedareasaremonitoredPFR.1.5AppropriateProtectionLeadersidentifyvulnerablepatientgroupsThoseprotectedinclude:Children,disabledindividuals,elderlyOthersidentifiedbythehospitalStaffmembersunderstandtheirresponsibilitiesforprotectionPFR.1.6ConfidentialInformationPatientsareinformedabout:Howtheirinformationwillbekeptconfidentialandaboutlawsandregulationsthatrequirethereleaseand/orrequireconfidentialityofpatientinformationPatientsarerequestedtograntpermissiontoreleaseinformationnotcoveredbylawandregulationPFR.2ParticipationinCarePoliciessupportandpromotepatientandfamilyparticipationincareprocessesPoliciesandproceduresaddresstherighttoseekasecondopinionwithoutfearofcompromisedcareStaffmembersaretrainedontheirroleinsupportingparticipationincareprocessesPFR.2.1PatientInformationPatients&familiesunderstandhowandwhentheywillbetoldaboutmedicalconditionsandanyconfirmeddiagnosisplannedcareandtreatmentwhenconsentswillberequestedandtheprocessusedtheirrighttoparticipateincaredecisionsPFR.2.1.1OutcomesofCarePatientsandfamiliesunderstandhowtheywillbetoldandwhowilltellthemoftheoutcomesofcareandtreatmenthowtheywillbetoldandwhowilltellthemofanyunanticipated

outcomesofcareandtreatment(outcomeoftreatmentincludingunanticipatedoutcome)PFR.2.2RighttoRefuseorDiscontinueCarePatientandfamilieswillunderstand:theirrightstorefuseordiscontinuecaretheconsequencesoftheirdecisionstheirresponsibilitiesrelatedtosuchdecisionsavailablecareandtreatmentalternativesPFR.2.3WithholdingResuscitation/WithdrawingLifeSupportHospitaldefinesitspositionHospital’spositionconformsto:Community’sreligiousandculturalnormsAnylegalorregulatoryrequirementsPoliciesguidepatientson:HowtomaketheirdecisionsknownHowtomodifydecisionsduringcarePolicies&proceduresguide:Hospital’sresponsetopatient’sdecisionsDocumentationaboutdecisionsTheethicalandlegalissuesrelatedtocarryingoutthepatient’swishesPFR.2.4AssessmentofPainTheorganizationrespectsandsupportsthepatient’srighttoappropriateassessmentandmanagementofpainStaffunderstandthepersonal,cultural,andsocialinfluencesonthepatientsrightto:reportpainaccuratelyassessandmanagepainPFR.2.5EndofLifeCareHospitalstaffrecognizesthatdyingpatientshaveuniqueneedsStaffrespectstherightofdyingpatientstohavethoseuniqueneedsaddressedinthecareprocessPFR.3ComplaintsandConflictsPatientsareawareoftheirrighttovoiceacomplaintandtheprocesstodosoThehospitalhasandusesamechanismtoreview:complaintsdilemmasthatariseduringcarePPidentifyparticipantsintheprocesshowthepatientandfamilyparticipatePFR.4EducationofStaffStaffmembersunderstand:theirroleinidentifyingpatientandfamilyvaluesandbeliefshowthesevaluesandbeliefscanberespectedinthecareprocesstheirroleinprotectingpatientandfamilyrightsPFR.5PatientsareInformedofRightsPatientsreceiveinformationabouttheirrightsinwritingThehospitalhasaprocesstoinformpatientsorfamiliesoftheirrightswhenwrittencommunicationisnoteffectiveorappropriateLanguageIlliteracyMedicalconditionPFR.6PatientsReceiveInformation

PolicyandprocedurecontainaclearlydefinedinformedconsentprocessPatientsgiveconsentconsistentlywithpolicyDesignatedstaffaretrainedconsistentlywithpolicyPFR.6.1AdequateInformationPatientsareinformedabout:theirconditionproposedproceduresandtreatmentsandwhoisauthorizedtoperformthempotentialbenefitsanddrawbacksandpossibleproblemsrelatedtorecoveryalternativestotheproposedtreatmentandresultsofpossiblenon–treatmentlikelihoodofsuccessoftreatmentsPatientsknowtheidentifyofthephysicianorpractitionerresponsiblefortheircarePFR.6.2OthersGivingConsentThehospitalhasaprocessforwhenotherscangrantinformedconsentTheprocessisconsistentwithlaw,culture,andcustomTheindividualgivingconsentisdocumentedinthepatient’srecordPFR.6.3GeneralConsentIfGeneralConsentisobtainedatthetimeofadmissionorregistrationforthefirsttimeasanout-patient,then:thescopeofaGeneralConsentiscleartheGeneralConsentisdocumentedperhospitalpolicyHowever,thestandardsdonotrequireaGeneralConsentPFR.6.4RequiredInformedConsentsConsentisobtainedbefore:SurgicalorinvasiveproceduresAnesthesiaotherthanlocalModerate(“conscious”)anddeepsedationBloodandbloodproductsHigh-riskproceduresandtreatmentsRequireddocumentationinthemedicalrecord:IdentityoftheindividualprovidinginformationtopatientandfamilyPatient’ssignatureorarecordofverbalconsentPFR.6.4.1SpecificConsentsThehospitalhasalistofthoseoperations,procedures,andtreatmentsthatrequireaseparateconsentThelistisdevelopedcollaborativelybyphysiciansandothersthatprovidethetreatmentsandperformtheproceduresPFR.7AccesstoResearchPatientswhomaybenefitfromparticipatinginresearchareidentifiedandinformedabouthowtogainaccesstoresearchPatientsaskedtoparticipateareinformedabout:ExpectedbenefitsPotentialdiscomfortsandrisksAlternativesthatmighthelpthemProceduresthatmustbefollowedRefusaltoparticipateorwithdrawwillnotcompromisetheiraccesstoservicesRelevantonlyifresearchisdoneinthehospitalPFR.7.1ResearchPatientsareProtected

Patientsandfamiliesareinformedaboutthehospital’sprocessfor:ReviewingresearchprotocolsWeighingthebenefitsandrisksObtainingconsentWithdrawingfromparticipationPFR.8InformedConsentforResearchInformedconsentisobtainedwhenthepatientdecidestoparticipateConsentdecisionsaredocumented,datedTheindividualprovidingtheinformationisdocumentedinthepatient’srecordConsentisdocumentedinthemedicalrecordbysignatureofthepatientorrecordofverbalconsent

PFR.9OversightofResearchTheorganizationhasacommitteeorothermechanismtooverseeresearch:Oversightincludes:AclearstatementofthepurposeofoversightactivitiesAreviewprocessAprocesstoweighrelativerisksandbenefitsProcessestoprovideconfidentialityandsecurityofresearchinformation

PFR.10OrganDonationThehospitalsupportspatientandfamilychoicestodonateorgansandothertissueprovidesinformationtosupportthechoicePFR.11Oversight

Policyandprocedureguide:theprocurementanddonationprocessthetransplantationprocessStaffistrained:inthepolicyintheissuesandconcernsrelatedtoorgandonationandtheavailabilityoftransplantsThehospitalcooperateswiththerelevantorganizationsandagenciesinthecommunitytorespectandimplementchoicestodonateThankYouNextPresentationAssessmentofPatients

(AOP)79AOP–ThreeAreasofFocusCollectingandAnalyzingPatientDataandInformationLaboratoryServicesRadiologyandDiagnosticImagingServicesAOP.1–AOP.1.1

AssessmentProcessAOP.1HospitalPP:definetheassessmentinformationtobeobtainedforinpatientsoutpatientsidentifytheinformationtobedocumentedfortheassessmentsAOP.1.1Thescopeandcontentofassessmentsaredefinedinpolicies:ForeachclinicaldisciplineForinpatientandoutpatientsettingsAOP.1.2InitialAssessmentInpatientsandoutpatientshaveaninitialassessmentthatmeetshospitalpolicy(NotethatbyAOP.1and1.1,inpatientandoutpatientassessmentsmaybeverydifferent)Initialassessmentincludes,accordingtohospitalpolicy:AmedicalassessmentincludingahealthhistoryandphysicalexaminationApsychologicalassessmentappropriatetoneedsSocialandeconomicasappropriatetoneedsContinuedonnextslideAOP.1.2InitialAssessment

Theinitialassessmentresultsin:UnderstandinganypreviouscareandthecarethepatientiscurrentlyseekingSelectingthebestsettingforthecareAninitialdiagnosisAOP.1.3Patient’sNeedsIdentifiedTheinitialassessmentresultsin:Identificationofpatient’smedicalneedsIdentificationofpatient’snursingneedsMedicalneedsareidentifiedbasedonthedocumentedH&PandotherrequiredhospitalassessmentsNursingneedsareidentifiedbasedonthenursingassessment,themedicalassessmentandotherrequiredhospitalassessmentsAOP.1.3.1AssessmentofEmergencyPatientsEmergencypatientshave:MedicalassessmentappropriatetotheirneedsandconditionNursingassessmentappropriatetotheirneedsandconditionIfemergencysurgeryisperformed,thefollowingarerecordedbeforetheoperation:AbriefassessmentnoteApreoperativediagnosisAOP.1.4–AOP.1.4.1TimeFramesAssessmenttimeframesareestablishedforallsettingsandservicesTheinitialmedicalandnursingassessmentsareconductedwithinthefirst24hoursorearlierasindicatedbythepatient’sconditionorhospitalpolicy(AOP.1.4.1)AssessmentsarecompletedintheestablishedtimeframesAssessmentsfromoutsidetheorganizationarereviewed/verifiedatthetimeofadmissiontoinpatientstatusAOP.1.4.1AssessmentsPerformedBeforeAdmissionForanyassessmentconductedmorethan30dayspriorto:admissiontoinpatientstatusoranoutpatientprocedure

themedicalhistoryhasbeenupdatedandthephysicalexaminationrepeatedForanyassessmentlessthan30daysold,anysignificantchangesinthepatient’sconditionarenotedatthetimeofadmissiontoinpatientstatusAOP.1.5AssessmentsareAvailableAssessmentsaredocumentedinthepatient’smedicalrecordIndividualscaringforthepatientcanfindandretrieveassessmentsasneededMedicalandnursingassessmentsaredocumentedwithin24hoursofadmissionForotherthanmedicalandnursingassessments,therecanbeasummarynoteinthepatient’srecord,withafullerdescriptionintheconcerneddepartmentaslongasthereisaccesstothem(seeIntentStatement)

AOP.1.5.1AssessmentsbeforeAnesthesiaorSurgeryMedicalassessmentisperformedpriortosurgeryMedicalassessmentisdocumentedpriortosurgeryAOP.1.6NutritionalandFunctionalScreeningQualifiedindividualsdevelopcriteriatoidentifypatientswhorequirefurthernutritionaland/orfunctionalassessmentPatientsarescreenedfornutritionalriskand/orfunctionalriskaspartoftheinitialassessmentPatientsidentifiedforadditionalassessmentbasedonthecriteriathatidentifiesadditionalneeds,receiveadditionalassessmentsfornutritionaland/orfunctionalneeds(Functionalriskmeanshavingoneormoreskillneededfortheactivitiesofdailylivingimpaired)AOP.1.7SpecialPopulationsThehospitalidentifiesspecialpopulations,includingatleast:VeryyoungpatientsFrailelderlyTerminallyillandothersinpainWomeninlaborThosewithemotionalorpsychiatricdisordersThosesuspectedofdrugand/oralcoholdependencyVictimsofabuseandneglectTheinitialassessmentisforthesepopulationsismodified(i.e.patientsbelongingtothesespecialpopulationsreceiveindividualizedassessments)91AOP.1.8SpecializedAssessmentsWhentheneedforadditionalspecializedassessmentsareidentified,patientsarereferredwithinoroutsidetheorganization,asappropriateAdditionalspecializedassessmentscompletedwithintheorganizationaredocumentedAOP.1.9DyingPatientsandTheirFamiliesDyingpatientsandtheirfamiliesareassessedandreassessedFindingsguidecareandservicesFindingsaredocumentedAOP.1.10

SpecializedAssessmentsPatientsarereferredwithintheorganizationwhentheneedforspecializedassessmentsareidentifiedCompletedanddocumentedAOP.2ReassessmentPatientsarereassessed:TodeterminetheirresponsetotreatmentToplanforcontinuedtreatmentordischargeAtintervalsappropriatetotheircondition,planofcareandindividualneedsandhospitalPPContinuedonnextslideAOP.2ReassessmentAphysicianreassessespatientsdailyduringacutephaseofcareDailymeansincludingweekendsandholidaysPolicydefineswhenphysicianreassessmentlessoftenthandailyisacceptablebasedon:Circumstances,typesofpatients,orpatientpopulations(i.e.definenon-acutepopulation)PolicyidentifiesthereassessmentintervalforthesepatientsAllreassessmentsaredocumentedAOP.3QualifiedIndividualsIndividualsqualifiedtoassessandreassessareidentifiedbythehospitalOnlythosepermittedbylicensure,applicablelawsandregulationsorcertificationscanperformtheassessmentsEmergencyassessmentsareconductedbyidentifiedandqualifiedindividualsNursingassessmentsareconductedbyidentifiedandqualifiedindividualsThosequalifiedtoconductassessmentsandreassessmentshavetheirresponsibilitiesdefinedinwriting(byclinicalprivilegeorjobdescription)AOP.4CollaborationtoIntegrateAssessmentsPatientassessmentdataandinformationareanalyzedandintegratedThoseresponsibleforthepatient’scareparticipateintheprocessAOP.4.1PatientNeedsPrioritizedPatientneedsareprioritizedbasedonassessmentresultsPatientsandfamiliesareinformedof:TheoutcomesoftheassessmentsandanyconfirmeddiagnosisasappropriateTheplannedcareandtreatmentandparticipateinthedecisio