Conscious Sedation

Mandatory for Clinical Care Providers Administering/Monitoring Conscious Sedation Only
Basic requirements of mild, moderate and deep sedation administration and patient monitoring. Includes pre and post sedation assessment and LIP credentialing requirements - JCAHO survey focus.

Length = 30 min

Discharge Planning and Patient Preparedness

Mandatory for Clinical Care Providers Only
Basic requirements of CMS and JCAHO for discharge patient assessment and planning, including planning for care in the home environment - covers pain management, equipment, medications and assistance required in home environment.

Length = 30 min

Informed Consent: Basic Principles for Staff Education

Mandatory for Clinical Care Providers Only
Basic requirements for providing and obtaining informed patient consent. Includes emergency consent, witnessing consent, consent for minors..

Length = 30 min

Medication Management

Mandatory for Clinical Care Providers Only
Comprehensive video of mandatory JCAHO requirements for medication management, covering the processes of medication selection and procurement, ordering/prescribing, preparation, dispensing, administration and monitoring the effects of medication on patients. Discusses medication error reduction including JCAHO focus on common areas of error, five medication rights, adverse drug reaction reporting, security and control of medications including emergency medications and controlled substances. Lists common medication management pitfalls noted during CMS and JCAHO survey.

Length = 45 min

Pain Management

Mandatory for Clinical Care Providers Only
Comprehensive video demonstrating the must know elements for successful compliance with the JCAHO Pain Management Standards. Includes key processes that lead to optimal pain management; mandatory JCAHO pain management requirements; how to best demonstrate compliance with these requirements; and types of pain management information that will be requested and examined during JCAHO accreditation survey. Covers each pain management standard within a given JCAHO function.

Length = 41 min

Patient Assessment

Mandatory for Clinical Care Providers Only
Basic requirements of CMS and JCAHO for initial and ongoing patient assessments. Including pain management, preoperative and postoperative assessments.

Length = 30 min

Patient Education

Mandatory for Clinical Care Providers Only
Basic requirements for CMS and JCAHO patient education, including medication, equipment, diet and disease management education.

Length = 30 min

Restraint and Seclusion: Catching the JCAHO Spirit

Collaborative video with the J.T. Posey Company addressing each of the JCAHO standards related to restraint use. Provides valuable education on how restraint and seclusion must be managed in healthcare institutions to comply with both JCAHO and federal restraint and seclusion standards. Included in the video and workbook are: requirements for primary behavioral health needs, requirements in the medical/surgical setting, clarification of restraint use in clinical protocols, restraint application and removal competency requirements, assessment requirements to determine restraint necessity, clarification of the "one-hour" physician evaluation rule, clarification of what constitutes restraint use for behavioral versus medical/surgical reasons. CEU credit available.

Length = 38 min

Victims of Abuse and Neglect: Meeting Identification and Reporting Standards

Mandatory for Clinical Care Providers Only
A comprehensive video educating healthcare organizations about the JCAHO requirements for identification and reporting of victims of abuse and neglect. The video outlines the JCAHO standards addressing this requirement and the impact this standard has on other JCAHO standards. Included in the video is a detailed explanation of signs and symptoms of child, elder and domestic abuse and neglect and a discussion of fiduciary abuse; and what the requirements are related to abuse/neglect documentation and reporting.

Length = 36 min

Admitting Services Department Survey

Comprehensive discussion and demonstration of JCAHO survey of Admitting Services. Includes necessity of medical screening, HIPAA regulations related to information received during admitting, EMTALA regulations.

Length = 30 min

Ambulatory Center Survey

Survey of all ambulatory center environments. Includes JCAHO, CMS and OSHA environment of care issues, physical inspection, anesthesia care, conscious sedation, postoperative patient evaluation, surveyor interviews, staff competency issues, medical record documentation requirements, medication management, PI and patient assessment/reassessment issues.

Length = 32 min

Care of Patients Interview

Reviews all JCAHO focus standards under the Care of Patients (TX) function, including: restraints, conscious sedation, medication management, operative procedures, anesthesia care, nutritional care, rehabilitation services, interdisciplinary care planning, and patient rights issues.

Length = 33 min

Central Processing Department Survey

Comprehensive discussion and demonstration of JCAHO survey of Central Processing. Includes management of hazardous materials, sharps injury prevention, sterilization, infection control practices in the environment and more.

Length = 33 min

CMS Validation Survey

CMS Validation Survey process includes surveyor focus related to Conditions of Participation, differences between JCAHO and CMS surveys. Demonstrates the CMS emphasis on physical inspection of the facility. Includes review of medical staff credential files, CMS’s quality assurance requirements, staff competency, staff education and training, life safety and environment of care issues, documents frequently requested for CMS review, staff interviews, medical record review, medication management and nutritional care issues.

Length = 56 min

Critical Care Unit Survey

Comprehensive discussion and demonstration of JCAHO survey of an ICU/CCU including staff competency, provision of emergency and critical care, patient assessment/reassessment, interdisciplinary provision of care, medication management, surveyor interviews with staff, patient rights and ethical concerns, restraint management and physical inspection of the ICU/CCU.

Length = 23 min

Emergency Department Survey

A comprehensive discussion and demonstration of JCAHO survey of the ED including patient rights issues, EMTALA regulations, security issues, identification and reporting of victims of abuse/neglect, staff competency, patient assessment, ED physical inspection and surveyor interviews with physicians and staff.

Length = 23 min

Environment of Care Survey

Comprehensive discussion and demonstration of JCAHO Environment of Care Survey for hospital environment. Takes viewer inside the survey process to observe what actually happens during the Environment of Care survey process, document review and building tour.

Length = 22 min

Human Resources Interview

Demonstrates the comprehensive JCAHO HR interview process and review of employee files. Includes clinical and age related competencies, performance evaluation requirements, competency of registry personnel, orientation processes, contracted and volunteer personnel requirements, and mandatory staff education and training.

Length = 24 min

Imaging Services Department Survey

A comprehensive discussion and demonstration of JCAHO survey of the Imaging Department including physical inspection issues, hazardous materials management, radiation safety, staff competency, patient assessment, provision of care, and surveyor interviews with physicians and imaging personnel.

Length = 28 min

Infection Control Interview

Demonstrates the JCAHO Infection Control interview process includes surveyor questions with IC nurse or epidemiologist – covers surveillance and control, BBP, employee health activities.

Length = 30 min

Information Management/ Medical Records Interview

Demonstrates the integrated JCAHO Information Management-Medical Record Interview - includes meeting compliance for current IM standards and actual medical record review. Outlines documentation requirements for: H&Ps, assessment/reassessment, operative procedures, pain management and informed consent.

Length = 25 min

Leadership Interview

Demonstrates the JCAHO Leadership interview process including surveyor questions with leadership responses to the key standards contained in the LD Function including provision of a safe environment, community involvement, patient rights, contracted services, PI, Patient Safety, ORYX / Core Measures, sentinel events, fraud and abuse and medical staff services/leadership involvement.

Length = 32 min

Maternal-Child Health Unit Survey

Comprehensive discussion and demonstration of JCAHO survey of the Maternal Child Health Unit addressing the key issues of infant abduction, assessment, pain management, nutritional screening, EMTALA requirements, staff competency, surveyor interviews and continuum of care issues impacting Maternal Child Health.

Length = 40 min

Medical Staff Credentialing Interview

Demonstrates the comprehensive JCAHO Medical Staff Credentialing interview process, includes physician interview and review of credential files. Highlights surveyor focus areas for: appointment/reappointment, peer review/physician competency, criteria for delineated clinical privileges, credentialing of AHPs, temporary privileges and the fair hearing process.

Length = 36 min

Medical Staff Leadership Interview

Demonstrates the comprehensive JCAHO Medical Staff Leadership Interview process. Includes interview with medical staff leaders and department chairpersons covering bylaws, organization of the medical staff, department director responsibilities, meeting requirements, responsibility for obtaining/providing education, medical staff officer requirements and chief of service obligations.

Length = 27 min

Nuclear Medicine Department Survey

A comprehensive discussion and demonstration of JCAHO survey of the Nuclear Medicine Department , including radiation safety, hot and cold laboratory inspection, staff competency, medication and radioactive materials management, provision of care, PI activities and surveyor interviews with physicians and imaging personnel.

Length = 25 min

Nursing Leadership Interview

Demonstrates the comprehensive JCAHO Nursing Leadership Interview process, covering such topics as: decision-making processes, staffing plans, staff competency, registry/contracted personnel, recruitment/retention, patient rights, restraints, standards of care, pt/family education, PI and department manager responsibility.

Length = 32 min

Nutritional Care Services Department Survey

Comprehensive discussion and demonstration of JCAHO NCS survey including physical inspection and tour including tray-line inspection, food preparation/storage, meal distribution, safety precautions, refrigerator/freezer maintenance, dry storage, infection control issues and dietitian interview during the patient care unit visit and the department director’s participation during the Care of Patients Interview.

Length = 21 min

Patient Care Unit Visit

Comprehensive discussion and demonstration of JCAHO survey of the Patient Care Unit including: surveyor/staff interviews, open record review, medication management, nutritional screening/assessment, rehabilitation services, staff competency, interdisciplinary care plans, patient rights, restraint management, PI and unit physical inspection.

Length = 30 min

Performance Improvement Interview

Demonstrates the JCAHO Performance Improvement Interview process, includes PI methodology, prioritizing PI activities, integration with patient safety, ORYX / core measure requirements, PI processes, measurement, evaluating outcomes, sustaining improvements, dimensions of performance and integration of JCAHO functions into organizational PI activities.

Length = 25 min

Pharmacy Services Department Survey

Comprehensive discussion and demonstration of JCAHO survey of Pharmacy Services. Includes surveyor inspection of pharmacy and medication management in other hospital areas and an interview with the pharmacy team. Addresses: staff competency, preparation, dispensing, ordering and administration of medication, adverse drug reaction reporting, food-drug reactions, formulary issues, sample medications and medication errors.

Length = 22 min

Post Anesthesia Care Unit Survey

Comprehensive discussion and demonstration of JCAHO survey of the PACU including surveyor interviews with staff, post-op patient assessment and discharge criteria, staff competency, PI activities, documentation issues, pain management, and physical inspection of PACU.

Length = 23 min

Random Unannounced JCAHO Survey

Comprehensive discussion and demonstration of focus issues commonly addressed during random unannounced JCAHO surveys. Review of medical staff credential files, staff competency, staff education and training, environment of care issues, staff interviews, documentation review, medication management and physical inspection.

Length = 49 min

Rehabilitation Services Department Survey

Comprehensive discussion and demonstration of JCAHO Rehabilitation Services Survey. Surveyor inspection and review of the Rehabilitation Services Department including interviews with staff, physical inspection of the department, functional assessments, reassessments, patient evaluations, patient/family education regarding treatment and equipment management, staff competency, patient safety, infection control, PI and life safety/emergency management issues.

Length = 28 min

Respiratory Therapy Department Survey

Comprehensive discussion and demonstration of JCAHO survey of Respiratory Services. Surveyor inspection and review of Respiratory Therapy Department including interviews with staff, medication management, staff competency, equipment education and training, patient safety, infection control, PI and life safety/emergency management issues.

Length = 21 min

Surgical Services Department Survey

A comprehensive discussion and demonstration of JCAHO survey of the surgical environment. Actual survey process includes physical inspection of department and surveyor interviews with staff. Includes: Pre-op patient preparation, anesthesia evaluation, infection control, informed consent, conscious sedation, physician competency, surgical complications, on-call staff, PI and sentinel events.

Length = 22 min

Basic Principles of Infection Control: Staff Education and Training

Basic general principles and practices of IC for all hospital staff. Provides education on OSHA requirements for prevention of exposure to bloodborne pathogens, including personal protective equipment, sharps injury protection and medical safety devices (needleless IV systems). Discusses transmission-based precautions and isolation categories. Actual demonstrations on how to comply with infection control regulations and focus on types of issues presented to staff during JCAHO accreditation survey.

Length = 23 min

Confidentiality and Patient Privacy: Basic Principles for Staff Education

Basic requirements from JCAHO and CMS related to confidentiality of patient information and patient privacy rights. Discusses scenarios where confidentiality and privacy can be compromised and how to avoid these pitfalls. Discusses verbal and written confidentiality of information, maintaining patient privacy throughout the healthcare institution.

Length = 30 min

Emergency Management: Staff Education and Training

Basic mandatory education requirements for all hospital staff related to emergency (disaster) management and preparedness includes bioterrorism threat and reaction. Includes four phases of emergency management with detailed description on management of each phase: mitigation, preparedness, response and recovery. Expands on emergency management requirements for plant services, administrative and key leadership. Addresses what all healthcare staff must know regarding emergency management, which areas, departments and personnel typically hold additional responsibilities in an emergency occurrence. Includes JCAHO survey focus component.

Length = 44 min

Fire (Life) Safety

Mandatory Training
Basic mandatory education requirements for all staff for fire prevention, safety and management. Expands on requirements for plant services, safety officers, patient care providers. Includes JCAHO focus component.

Length = 27 min

General Safety for Healthcare Workers

Mandatory Training
General safety mandatory requirements for all hospital staff. Basic hospital safety components including hazard surveillance, incident reporting and activities that reduce the risk of injuries to personnel, visitors and patients.

Length = 30 min

Hazardous Materials and Waste Management

Mandatory Training
Basic mandatory education for all staff for hazardous materials and waste management. Includes prevention of exposure, safe handling and transporting, spill handling, basic blood borne pathogen safety and general precautions.

Length = 30 min

HIPAA: Basic Principles for Staff Education

Basic principles of HIPAA and explanation of what HIPAA (the actual act) is and why it is necessary. Includes outline of requirements and compliance responsibilities overall, discussion of types of information and how the information is generated within a healthcare organization. Discussion of consent and authorization requirements, confidentiality and protection of personal health information. Minimum necessary standards for healthcare worker compliance. Covers HIPAA guidelines related to clerical (Admitting, Business office, Medical records staff), clinical healthcare providers, and those providers that must address psychotherapy notes. Covers HIPAA requirements for information sharing internally and externally, and components of a HIPAA compliance plan and program.

Length = 28 min

Managing a Bioterrorist Event: Staff Education and Training

Discusses the types of bioterrorism attacks that may be experienced; covert or announced, and the required recognition and response to each types of attack. Outlines types of bioterrorism, including biochemical attacks. Comprehensive description of signs, symptoms and treatment for the most likely biological weapons. Includes actual footage of a Bioterrorism Drill with community participation. Discusses impact of bioterrorist attack on healthcare community.

Length = 30 min

Medical Equipment Management

Mandatory Training
Basic mandatory education for all staff related to general equipment safety policies including requirements for orientation to new equipment, reporting malfunctioning equipment and emergency procedures in the event of equipment failure. Includes JCAHO survey focus. Expands on biomedical engineering's and departments responsibilities for biomedical equipment management.

Length = 30 min

Patient Rights

Mandatory Training
Basic CMS and JCAHO requirements for patients rights including right to appropriate pain management, spiritual and religious rights, right to grievance, right to safe and secure environment, and right to optimal care.

Length = 43 min

Performance Improvement: Basic Principles for Staff Education

Mandatory Training
Principles of PI for overall hospital staff education, expands clinical care provider responsibility related to patient care and patient safety standards, includes sentinel event reporting, root cause analysis, medical health care error reporting and continuously improving processes and systems within a given function - JCAHO survey focus.

Length = 30 min

Security Management

Mandatory Training
Basic mandatory security education for all staff with focus on high alert areas of the institution. Expands on security officer and security "alert" situations. JCAHO survey focus.

Length = 30 min

Utility Systems and Medical Gas Management

Mandatory Training
Basic mandatory education for all staff related to utilities systems management and medical gas management. Includes measures for all staff in event of utilities failure or "shut down" situation. Includes safe medical gas handling and precautions. Expands on plant services and responsible departments for utilities and gas management. JCAHO survey focus.

Length = 30 min