Courtemanche & Associates: Preparing For Joint Commission

HOSPITAL PLAN FOR THE PROVISION OF PATIENT CARE

Planning Defines:

 Mission, Vision, Values

 Assess Patients needs; internal / external customers

 Long range, strategic and operational plans

 Patient Safety

 Proactive Patient Safety

 Role in Sentinel Events

 Sentinel Event Alerts

 Performance Improvement Priorities

 Communication of plans and goals

 Budgets / Resource Allocation

 Policies / Procedures

 Space / Safety / Maintenance / Special Activity Areas

 Access / Supervision of grounds and equipment

 Clinical services / Ages and characteristics of populations serviced

Case Mix / Technology

 Important Patient and Organizational Functions

 Care of patients under legal and corrective restrictions

 Use of seclusion / restraint (non-clinical)

 Imposition of disciplinary restrictions

 LOS

 Restriction of rights

 Plan for discharge and continuing care

 Patient care services based on identified needs

 Education

 Patient care expectations

 Description of care and services

 Setting priorities

 Consideration of human and material resources for education

 Consideration of mission and resources related to research activities

 Planning collaborative process: Includes at least administrative, medical staff

leaders, community leaders (CEO, CMS, CNO, Governing Body)

 Use of Clinical Practice Guidelines

 Services are designed to respond to patient / family needs and expectations

 Services are timely and appropriate to scope and level of care needed by

patients served

 Medical staff approves sources of care outside the hospital

 Outside sources of care have written agreements that meet TJC standards

 Reset performance improvement priorities in response to unusual or urgent

events

 Provided framework / criteria for establishing performance improvement

priorities to assure high risk, high volume, problem prone processes are

addressed

 Annual operating budget / Governing Body approval / annual audit

 Provides uniform performance of patient care processes

 Departmental scope of services approved by administration and medical staff

 Collaborative decision-making: leaders and others

 Development of hospital wide patient care programs, policies,

procedures for assessment of patient care needs

 Implementation of plan for provision of care

 Decision making structures and processes

 Implementation of effective and continuous programs to measure /

assess / improve / and sustain improvement

 Recruit / Retain / Develop / Continuing Education for all staff

 Programs to promote job related advancement and educational goals

 Staff identified learning needs