Preparing the Pharmacy for a Joint Commission Survey : Tips for a Successful Joint Commission Survey
by Coe, Charles P.; Uselton, John P.; Joint Commission on Accreditation of Healthcare Organizations; American Society of Health-System PharmacistsEdition: 5th
Format: Paperback
Pub. Date: 2003-01-01
Publisher(s): Amer Soc of Health System
Other versions by this Author
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Summary
The new fifth edition of this comprehensive publication contains reliable single-source documentation of the JCAHO accreditation standards that relate to pharmacy practice, their interpretation, and all the hands-on guidance necessary to ideally prepare for your pharmacy accreditation survey. Content includes an overview of the JCAHO survey process, as well as helpful checklists, forms, and comparative examples to help pharmacies meet pertinent JCAHO requirements.
Table of Contents
| About the Authors | p. vii |
| Acknowledgments | p. vii |
| Reviewers | p. vii |
| Introduction | p. ix |
| Improvements to the Fifth Edition | p. ix |
| Overview of This Book | p. ix |
| Joint Commission on Accreditation of Healthcare Organizations | p. 1 |
| Accreditation | p. 1 |
| Why Organizations Seek Accreditation | p. 1 |
| Legal Status of Standards | p. 1 |
| Comprehensive Accreditation Manual for Hospitals: The Official Handbook | p. 2 |
| Other Joint Commission Standards Manuals | p. 2 |
| Using Joint Commission Standards to Justify Improved Services | p. 2 |
| Additional Joint Commission Resources | p. 3 |
| American Society of Health-System Pharmacists Resources | p. 5 |
| Other Resources | p. 5 |
| Joint Commission Surveys | p. 7 |
| Before the Survey | p. 7 |
| Survey Length and Survey Teams | p. 10 |
| Initial Sessions | p. 11 |
| Visits and Interviews | p. 12 |
| Survey Team Meeting | p. 13 |
| Leadership Exit Conference | p. 14 |
| Accreditation Decisions | p. 14 |
| Focused Surveys and Written Progress Reports | p. 15 |
| Other Surveys | p. 15 |
| What to Expect in Future Surveys | p. 17 |
| Looking Ahead | p. 17 |
| Checklist for Compliance with Joint Commission Standards | p. 19 |
| Terms Used in the Checklist | p. 19 |
| Codes Used in the Checklist | p. 19 |
| Notes on Standards in the Checklist | p. 19 |
| Using the Checklist | p. 20 |
| Table of Contents for the Checklist | p. 21 |
| Checklist | p. 22 |
| Exhibits | |
| Joint Commission Patient Safety Standards Checklist | p. 90 |
| Suggested Policies and Procedures Checklist | p. 97 |
| Frequently Requested Documents Checklist | p. 108 |
| Pharmacy and Medication Areas Checklist | p. 116 |
| Safety Checklist | p. 123 |
| Infection Control Checklist | p. 132 |
| Appendices | |
| Example Survey Agendas | p. 143 |
| Pharmacy Services Visit | p. 158 |
| Patient Care Setting Visits | p. 160 |
| Patient Care Interview | p. 174 |
| Department/Service Directors Interview | p. 197 |
| Questions for Hospital Directors, Department Managers, and Staff | p. 198 |
| Competence Assessment | p. 209 |
| Overview of the Joint Commission's Improving Organizational Performance Standards | p. 212 |
| Performance Improvement Team Presentation | p. 216 |
| Overview of the Joint Commission's ORYX Initiative | p. 221 |
| Overview of the Joint Commission's Sentinel Event Policy | p. 223 |
| Medication Safety Improvement | p. 225 |
| Adverse Drug Reactions | p. 243 |
| Overview of the Food and Drug Administration's MedWatch Program | p. 253 |
| Overview of the Occupational Safety and Health Administration's Hazard Communication Standard | p. 255 |
| American Osteopathic Association Surveys | p. 257 |
| Medicare Surveys | p. 284 |
| Example Forms and Documents | |
| Suggested Activity Frequency Chart | p. 291 |
| Verification of Licensure Form | p. 292 |
| Individuals Who May Remove Drugs From the Pharmacy Form | p. 293 |
| After-Hours Pharmacy Competence Checklist | p. 294 |
| After-Hours Log | p. 296 |
| After-Hours Log Deficiency Record | p. 297 |
| Night Cabinet Proof of Use Form | p. 298 |
| Job Description, Competence Assessment Summary, and Performance Evaluation | p. 299 |
| Competence Assessment Test (Pediatric and Adolescent Patients) | p. 305 |
| Competence Assessment Skills Checklist (Pediatric and Adolescent Patients) | p. 309 |
| Orientation Record | p. 310 |
| Education Program/Meeting Record | p. 312 |
| Continuing Education Record | p. 313 |
| Request for Formulary Addition Form | p. 314 |
| Nonformulary Drugs List | p. 315 |
| Nonformulary Drug Request Form | p. 316 |
| Drug Sample Receiving Log | p. 317 |
| Drug Sample Dispensing Log | p. 318 |
| Drug Sample Receiving/Dispensing Log | p. 319 |
| Recalled Drug and Device Inspection Record | p. 320 |
| Emergency Supplies Inspection Record | p. 321 |
| Power of Attorney for DEA Order Forms | p. 322 |
| Controlled Substances Inventory Cover Page | p. 323 |
| Controlled Substances Inventory Record | p. 324 |
| Registrants Inventory of Drugs Surrendered | p. 325 |
| Report of Theft or Loss of Controlled Substances | p. 327 |
| Medical Staff Information Record | p. 329 |
| Confidentiality of Patient Information Agreement | p. 330 |
| Refrigerator/Freezer Monthly Temperature Log | p. 331 |
| Refrigerator/Freezer Yearly Temperature Log | p. 332 |
| Refrigerator/Freezer Monthly Temperature Graph | p. 333 |
| Medication Area Inspection Record | p. 334 |
| Inspection Assignment Grid | p. 335 |
| P & T Committee Agenda and Minutes Guidelines | p. 336 |
| Policy and Procedure for Nonformulary Drug Requests | p. 340 |
| Laminar Airflow Hood Cleaning Record | p. 341 |
| Intravenous Admixtures Competence List | p. 342 |
| Patient's Personal Drugs List | p. 343 |
| Receipt and Disposal of Patient's Personal Medications Record | p. 344 |
| Medication Error Report | p. 345 |
| USP Medication Errors Reporting Form | p. 347 |
| Adverse Drug Reaction Report | p. 349 |
| Adverse Drug Reaction Rates Summary Chart | p. 351 |
| Assessment of Suspected Adverse Drug Reaction Report | p. 352 |
| Adverse Drug Reaction Summary Report | p. 354 |
| Notice of Drug Reaction Form | p. 355 |
| FDA MedWatch Report Form | p. 356 |
| Vaccine Adverse Event Reporting System Form | p. 358 |
| Intervention Log | p. 360 |
| References | p. 361 |
| Index | p. 362 |
| Table of Contents provided by Syndetics. All Rights Reserved. |
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