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Gina Ward
JCAHO coming in 3 weeks

 

Hello there again.   We have JCAHO coming in 3 weeks and I was wondering if anyone has been visited by them recently.  I am a one woman PICC team.  I do all the insertions, dressing and cap changes and trouble shooting. 

If anyone has heard or been visited by them lately do you have any info on key points of interest or things they were looking for?

I know there is a great push for prevention of BSI and central lines and insertion checklists; anyone been grilled by them on this and what kind of things are they looking for.

 

Thanks in advance, Gina Ward R.N, C.P.A.N.

 

kunzerod
JCAHO visitation

Gina:  We just fininshed our JCAHO cert.  The team that evaluated us were most concerned about using the central line bundle for insertion with maximal barrier protection.  The other point was that a proper time out be performed prior to insertion.

Rod D. Kunze RN, RCIS

Action Site Manager, Door 2 Balloon coordinator

PICC coordinator

St Vincent Healthcare

1233 North 30th

Billings, Montana 59101

 Work    (406) 237-4300

FAX      (406) 237-4390

Beeper (406) 237-7788 #068

[email protected]

 

Rod D. Kunze RN, RCIS Action Site Manager, Door 2 Balloon coordinator PICC coordinator St Vincent Healthcare 1233 North 30th Billings, Montana 59101  Work    (406) 237-4300 FAX      (406) 237-4390 Beepe

kratz
We were just visited as well.

We were just visited as well. They wanted to see consent, pt. education, documentation and sterile bedside checklist.

Karen Ratz,RN St. Lukes Hospital, Cedar Rapids,IA

Gina Ward
surveyors

 

Regarding the sterile bedside checklist.  Did they look for another person observing you and checking you off as we have discussed some on the forum? or just that you have a list you go by to be sure you are following the guidelines?

  Did they actually follow you around and observe( consents, educations and insertion)  as well as ask to see things and how you were performing? 

 

Thanks,  Gina

Gina Ward R.N., VA-BC

kratz
JCAHO

They did not follow us around. They did chart reviews looking for consents. They met with our infection control nurses who showed them our database with all our completed sterile bedside checklist and insertion information..We do keep a laminated checklist on our cart which our assistant fills out and then inputs the data into our database. I did meet with them briefly and discussed our process of pt. education. We have a PICC pt. education pamphlet and they asked to see that.

Karen Ratz,RN St. Lukes Hospital, Cedar Rapids,IA

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