What surveyors found in patient, system tracers
During a February 2008 Joint Commission survey at Temple East/Northeastern Hospital, a 187-bed community hospital in Philadelphia, surveyors asked several staff members if they knew how to contact The Joint Commission about quality or safety concerns.
"We have developed a poster telling staff, patients, families, and physicians that if they have concerns about quality and patient safety issues that they can contact the Department of Health or The Joint Commission," says Sherry Mazer, FACHE, CPHQ, regulatory officer at Temple University Health System in Philadelphia. "They are hanging in elevators and bulletin boards on the patient care units and other departments."
The question underscored the "staff-driven" nature of the survey, says Sally Hinkle, RN, BSN, MPA, Temple East/Northeastern's director of quality management. "Managers were present, but it was clear that the surveyors wanted to speak with the staff about their processes and how they were delivering quality, safe patient care," she says.
Here are some areas surveyors looked at during system tracers:
• Data use tracer:
"The surveyors started with the core measures, which were most problematic from the data that they received," says Mazer. "We weren't improving one of the measures in one of our core measure sets very quickly. We did a detailed analysis of that measure showing results over time, and action plans for quicker compliance. They were very satisfied with our analysis."
• Medication management tracer:
Surveyors asked these questions:
— What is the pharmacy's role in medication reconciliation?
— How are medications obtained when the pharmacy is closed?
— Are patients or physicians allowed to bring in their own medications?
Surveyors then traced a patient on heparin, and wanted to see how the order for a high-risk medication was handled by pharmacy and nursing, and checked for a double signature before the drug was given.
• Infection control tracer:
Surveyors did a detailed review of dialysis machine testing, and reviewed flash sterilization logs and policies. "The surveyor also observed the dialysis nurse providing a treatment, checking to see that she properly reviewed the patient's identification using two identifiers, used good hand hygiene, and wore the proper personal protective equipment," says Mazer.
• Environment of care tracer:
"A very thorough building tour was done by the Life Safety Specialist," says Mazer. "The surveyor found equipment in front of electrical panels, which was not allowed even though the equipment was on wheels."
All testing logs were reviewed, including fire suppression systems and generator testing, and fire doors were checked, with the surveyor finding one with a gap that was too large.
The administrative surveyor closely reviewed the hospital's emergency preparedness program. "He read the emergency operations plan, and looked at our drill after-action reports and hazard vulnerability analysis," says Mazer. "He asked a lot of questions about the emergency supply inventory, and toured our new incident command center, ED, emergency supply shed, and decontamination area. He was impressed with the amount of supplies that we maintain."
The surveyor asked to see medical staff credentialing files for the most recent appointment to staff, the senior dentist, the after-hours radiologist, the most recently appointed podiatrist, the latest physician to be granted a new privilege, and any physician with involuntary reduction in privileges. "He congratulated the medical staff coordinator on the consistent detail she used in all of the required checks," says Mazer.
The surveyor reviewed the files with the chief medical officer and medical staff office personnel first, then interviewed the medical staff members. Regarding the requirement for an ongoing review of practitioners, the surveyor said that one year was too long of a timeframe, and that six to nine months was acceptable. "We have decided to change to providing the ongoing practitioner profile every six months," says Mazer.
For all of the patient tracers, surveyors looked for completeness of the history & physical, legibility, and that notes and verbal orders were authenticated with time, date, and signature. "The timing of chart entries was a big focus, especially since CMS updated their conditions of participation in late 2006 to include this," says Mazer.
Surveyors liked the form used for verbal orders, which has a flag sticking out of the chart for the physician to see, and can be torn off once it's signed. "All the rules for taking and signing a verbal order are on the form — verbal order read back, sign within 24 hours, date and time," says Hinkle.
Here is what surveyors looked for in specific units:
• In the post-anesthesia care unit: The surveyor checked for evidence of the time out, post-operative note, signed consents, medication reconciliation, and competencies for staff that he interviewed.
• In the ED: An ED nurse was asked about the competencies and certifications needed to care for a patient receiving moderate sedation. The nurse was also asked about medication reconciliation, peak flows, reassessments, turnaround time for lab values and critical values, patient identifiers, and the process for accessing interpreters.
• In the intensive care unit: The surveyor asked about processes for medication reconciliation, assessment of deep venous thrombosis, high-alert medications, vaccination assessment, isolation, addressing medical staff abusive behavior, and nursing orientation.
A staff nurse was interviewed about the communication process used for shift report, and the process for contacting the previous nurse with questions or concerns after the shift has started.
Last year, the organization did an intensive, mandatory education program on hand-off communications using the "situation background assessment recommendation" (SBAR) format. "It paid off, because all disciplines were able to speak to the process and show the forms and reports that are used," says Mazer.
[For more information, contact:
Sally Hinkle, RN, BSN, MPA, Director of Quality Management, Temple East/Northeastern Hospital, 2301 E. Allegheny Ave., Philadelphia, PA 19134. E-mail: [email protected].
Sherry Mazer, FACHE, CPHQ, Regulatory Officer, Temple University Health System, 2450 W. Hunting Park Ave., Philadelphia, PA 19129. Phone: (215) 707-6763. Fax: (215) 707-8533. E-mail: [email protected].]
During a February 2008 Joint Commission survey at Temple East/Northeastern Hospital, a 187-bed community hospital in Philadelphia, surveyors asked several staff members if they knew how to contact The Joint Commission about quality or safety concerns.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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