Plans form the basis for many of your PI activities
Here are four of the plans JCAHO requires
By Patrice Spath, ART
Brown-Spath Associates
Forest Grove, OR
The Joint Commission’s standards require hospitals to develop and maintain several types of patient care and administrative plans. These plans form the basis for many of your performance improvement (PI) activities. Before any detailed work commences on writing a plan, the person or committee responsible should determine the Joint Commission’s requirements in relation to the content and level of detail. A typical plan should include the following main elements:
• brief introduction setting out the background and structure of the plan;
• summary highlighting the main issues;
• main body containing divisions broken into numbered sections and subsections;
• appendices containing tables, detailed information, exhibits, and so on referred to in the text.
Avoid unnecessary jargon in your plan. Use short, crisp sentences and bullet points, concentrating on relevant and significant issues. Break the text into numbered paragraphs and sections, and relegate detail to appendices. Once all the main issues pertinent to the subject have been defined by the organization and added to the content outline, it’s time to obtain the necessary approvals. At a minimum, written plans should be formally approved by the hospital’s governing board and medical staff executive committee.
In last month’s Quality-Co$t Connection, four of the plans required by the Joint Commission were described. This month, six more are detailed. In the last of this three-part series, in next month’s column, the remaining three plans will be presented.
PI plan
The hospital’s leaders are responsible for adopting an approach to PI that provides for planning the improvement process, setting improvement priorities, systematically assessing performance, implementing improvement activities based on assessment, and maintaining achieved improvements. The approach must be communicated throughout the organization, and a written plan is an important tool in this communication process. It should describe:
• the organization’s quality mission and goals/objectives of PI activities;
• the program structure and content;
• the role, structure, function, and frequency of meetings of the oversight committee and other relevant groups;
• the important functions performed by each department;
• how improvement priorities are selected (including the criteria used, if any);
• mechanisms for collaboration and integration among departments;
• how care and services provided to high-risk patients are evaluated and improved;
• methods for managing information, including reporting structure and frequency and how results are assessed;
• mechanisms for addressing individual performance;
• how PI documents are kept confidential;
• the process for performing an annual evaluation of the program’s effectiveness.
While not required by the Joint Commission’s standards, some hospitals create separate plans to describe their PI activities relevant to assessing and improving medication usage, blood usage, and operative/invasive procedures. Most hospitals integrate a discussion of these activities into their organizationwide PI plan. Be sure to describe what mechanisms have been established to assess the key activities in the functions of medication usage, blood usage, and operative/invasive procedures. It may be useful to create a matrix of performance measures for each function, to illustrate the extent of measurement and improvement activities and include them as attachments to your plan. (See matrix, p. 145.) Other plan attachments may include the organization’s current strategic quality plan and educational activities and a diagram showing methods of communication.
Medical record review plan (IM.3.2.1)
The process used to evaluate and improve the quality of medical record documentation can be incorporated into the overall PI plan or developed as a separate document. Be sure to include a definition of what constitutes a complete medical record in your organization; consider using the definition found in IM.7 in the Comprehensive Accreditation Manuals for Hospitals. Your definition may influence the delinquency rate statistics you compile.
Restraint and seclusion plan (PI.3.1.1)
The need for a restraint/seclusion plan is implied in the PI standard. This plan should address the following issues:
• mechanisms in place to protect and preserve patients’ rights, dignity, and well-being when restrictive measures are used;
• how patients are assessed and how caregivers base the use of restrictive measures on the assessment findings;
• the organization’s definition of preventive strategies and least restrictive methods;
• mechanisms to assure that staff are competent to apply and remove restraints;
• systems for monitoring and reassessing the patient during use;
• how caregivers meet the patient’s needs during use of restrictive measures;
• a declaration that orders for restraint and seclusion can only be made by licensed independent practitioners;
• a declaration that all orders are to be time-limited;
• what must be documented in the patient’s medical record;
• the PI priorities of the organization (focused on reducing the use of restraint and seclusion).
It is acceptable to include the restraint and seclusion plan as a section in the overall PI plan, rather than creating a separate document. The Joint Commission surveyors will assess your compliance with the plan during closed and open medical record review activities.
Patient and family education plan (PF.4)
This plan should describe the organizationwide mechanisms for planning, supporting, and coordinating education activities and resources. The hospital should have a defined process for assessing educational needs, considerations, and barriers and fulfill these requirements in a collaborative, interdisciplinary fashion — don’t forget patient/family collaboration. Right now, the Joint Commission is focusing particularly on medication instruction and food/drug interactions, so be sure your plan describes these education systems.
Infection surveillance, prevention, and control plan (IC.1)
This plan should describe the organization’s process for infection surveillance, prevention, and control. The role of the infection control committee should be detailed, as well as the responsibilities of the infection control practitioner. There should be evidence that the committee plays an active role in decision making and in determining appropriate/adequate resources for the program. Don’t forget to describe the consultative role of infection control practitioners in human resource issues (screening for employee infections, management of contagious diseases, etc.) and new construction (evaluating adequacy of ventilation systems, appropriateness of route of debris material removal, etc.). Be sure to also describe how the organization ensures that infection control activities comply with pertinent federal and state regulations.
Risk management plan
A risk management plan is not specifically required by the Joint Commission’s standards. It is considered to be one of the many components of an organization’s PI program, and, as such, the need for a plan is implied by the standards. A comprehensive risk management program consists of a risk identification/evaluation process, risk control measures, risk financing mechanisms, and an administrative function. The formal written statement should include a clear delineation of responsibility and accountability for all facets of the risk management program, to include:
• a statement of the risk management program objectives;
• a definition of the risk management process;
• indication of a periodic review by administration;
• person or group assigned the ultimate responsibility for program implementation and maintenance;
• how risk management activities are integrated with the organization’s overall PI program.
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