Surveyors want up-to-date info, detail in documents
Obtain patients' medication lists, and label all meds
(Editor's note: This month, we look at tips and suggestions from outpatient surgery programs that have undergone surveys in recent months from the Joint Commission on Accreditation of Healthcare Organizations. In a future issue, we will present tips and suggestions from organizations surveyed by the Accreditation Association for Ambulatory Healthcare.)
Medication reconciliation, labeling medications, staff competency, and Life Safety Code requirements were all topics upon which surveyors focused for organizations surveyed by the Joint Commission on Accreditation of Health-care Organizations in the past six months.
Managers at Manatee Surgical Center in Bradenton, FL, knew that National Patient Safety Goals would be a focus of the survey. "But even when you know about it and when you prepare for questions about your processes to meet these goals, you will have outliers, or staff members, that don't follow procedure," warns Linda M. Nash, MBA, CASC, LHRM, administrator and risk manager for the center and partner in Global Surgical Partners, a surgery center development and management firm in Bradenton, FL. "Our policy is to label all medications used in the operating room, but one of the certified nurse anesthetists [CRNAs] in our center who was the last staff person interviewed by the surveyor made an exception to our policy," she says.
The surveyor had observed a number of procedures with no deficiencies noted, but as he was preparing to leave the facility, he saw the CRNA and asked her one final question, she explains. When asked about labeling medications in the operating room, the CRNA stated, "I label all medications except Diprivan [AstraZeneca, Wilmington, DE] because it is the only white medication in the room."
"We were cited on this item because you can label 99 out of 100 medications, but that one that you don't label results in a deficiency," Nash says.
Reconciling medications is also a challenge for outpatient surgery programs, admits Nash. "When patients go into the hospital, they are more careful about making a list of all of their medications because it seems more serious," she says. "With outpatient surgery, patients don't see it as a serious issue so they are less likely to remember to tell you about everything."
Nash's staff starts building the list of medications for each patient with the physician's history and physical. When they noticed that the physician often stated "see list" to refer to a crumpled piece of paper on which the patient had scribbled the names of some items, they developed a more comprehensive list that is now given to the patients by the physician for completion before the day of surgery. [Editor's note: A copy of this form is available with the on-line version of Same-Day Surgery. If you're accessing your on-line account for the first time, go to www.ahcpub.com. Click on the "Activate Your Subscription" tab in the left-hand column. Then follow the easy steps under "Account Activation." If you already have an on-line subscription, to go www.ahcpub.com. Select the tab labeled "Subscriber Direct Connect to Online Newsletters. Please select an archive." Choose "Same-Day Surgery," and then click "Sign on" from the left-hand column to log in. Once you're signed in, select "2006" and then select the July 2006 issue. For assistance, call Customer Service at (800) 688-2421.]
"When our nurses make their pre-op calls, they remind the patient to complete the form and bring it with them on the day of surgery," she says. "If they lost the form, or if they seem confused by it, we ask them to bring in all of their pill bottles, for prescription and over-the-counter medications, and we fill in the form for them."
Compliance with Life Safety Code
In addition to looking at clinical issues and patient safety goals, the surveyor who visited the HealthSouth Surgical Center of Elizabethtown (KY) looked carefully at the outpatient surgery program's compliance with the Life Safety Code. Robin Boles, administrator of the center, says, "We were very surprised at how much time the surveyor evaluated our hazard vulnerability analysis and items such as firewall penetration. They had moved into a new building 12 months before the survey, so they believed that because they had recently undergone building inspections from the state, not as much time would be spent on this are.
"We did notice that the surveyor was especially interested in making sure that our hazard vulnerability analysis had been updated and changed to reflect our new building," she adds.
Staff competencies important
Not only did her surveyor want to see the organization's policy on Clinical Laboratory Improvement Amendment (CLIA)-waived testing, but Nash learned that simply observing employees perform the tests was not enough to prove competence.
"Our team leaders have always observed and documented their observations of employees who perform our hemoglobin, hematocrit, blood glucose, or pregnancy tests, but the surveyor wanted to see two forms of competency assessment," she says. Now, in addition to supervisor observations, all employees who perform these tests must take a written test, developed in-house to reflect their policies, as part of the competency assessment, Nash says.
Thorough documentation also is required to address standards related to the handling of human tissue, Nash says. "While we have standardized forms, we were told to add more detail to include where the tissue came from, all of the information related to the tissue bank, how the tissue has been stored and transported along the way, and who is responsible for the tissue once it is in our facility," she says. "We have enhanced all of those forms."
While Boles was not unhappy with the results of her survey, she does admit that she made a mistake when she invited all staff members to the exit interview with the surveyor. "Throughout the survey, I heard the surveyor praising us and using words such as 'stellar' and 'excellent,' so I did not expect to hear about any deficiencies," she explains.
The surveyor did point out some deficiencies and some processes that should be improved during the exit interview. Even though they were not major and were easily corrected, Boles' staff members took the report as criticism of them, she says. "Next time, I will meet with the surveyor and a few key supervisors, then report back to the staff," she says. "This will enable me to put the comments in perspective and make it less threatening to staff members."
Sources
For more information about survey experiences, contact:
- Robin Boles, Administrator, HealthSouth Surgical Center of Elizabethtown, 108 Financial Drive, Elizabethtown, KY 42701. Telephone: (270) 737-5200. E-mail: [email protected].
- Linda M. Nash, MBA, CASC, LHRM, Manatee Surgical Center, 601 Manatee Ave. W., Bradenton, FL 34205. Telephone: (941) 745-2727. E-mail: [email protected].
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