Education on 'do-not-use' abbreviation list needed
Physician orders, staff competency compliance issues
(Editor's note: This is the second of a two-part series that looks at accreditation standards that pose compliance problems for home health agencies. Last month, we looked at emergency preparedness and what components are necessary to satisfy a surveyor. This month, we examine do-not-use abbreviation lists, written orders, and competency assessments.)
Meeting the Oakbrook Terrace, IL-based Joint Commission on the Accreditation of Healthcare Organizations' patient safety goal that calls for a list of abbreviations not to be used because they can be misunderstood or misread, resulting in potential safety risk to a patient, seems like an easy task to achieve. The standard that reflects the appropriate use of abbreviations (IM 3.10) is, however, the second most problematic standard for organizations accredited by the Joint Commission with 16% of home health agencies found non-compliant.
"Everyone has their lists of 'do-not-use' abbreviations but home health agencies are finding themselves non-compliant because they are not providing the staff education needed to implement the do-not-use lists consistently," says Maryanne L. Popovich, RN, MPH, executive director of home care accreditation for the Joint Commission.
In addition to educational inservice on the do-not-use abbreviations, staff at Midwest Home Health in Del City, OK, have laminated reference cards that include the abbreviations and serve as a reminder not to use certain ones, says Sue Gibson, RN, director of the agency. "When the first core group of abbreviations was published we laminated bright pink index cards that contained the abbreviations, then we updated them when the next group was identified," she says. "The cards are taped to nurses' clipboards so they always have a quick, easy reference tool."
Gibson's agency also audits charts on a monthly basis, with staff members looking for use of banned abbreviations. "We audit the charts at different points of the patient's care, not just prior to filing a claim," she says. "We pick up problems such as a nurse who is using do-not-use abbreviations early in the process so we can make sure the nurse has the reference card and understands the importance of not using certain abbreviations," she says.
In a recent Joint Commission survey, the surveyor found only one do-not-use abbreviation that was used in a medication profile, says Gibson. "The surveyor reviewed a number of charts, so we were pleased that there was only one abbreviation misused," she adds.
A key to successfully implementing a do-not-use abbreviation list is to keep the list manageable, suggests Gibson. "We review the abbreviations carefully and include only those abbreviations that are really applicable to our practice," she says. If your list becomes too long, and includes abbreviations your staff rarely uses anyway, nurses will not use the reference tool because it is too time-consuming and cumbersome, she adds.
Physician order must be in chart
Another tough standard for home health agencies that resulted in non-compliance in 15% of agencies surveyed is the requirement that care be provided according to a physician's order, points out Popovich. "This standard has always been in the list of top 10 standards that pose compliance problems," she says. "The challenge for home health nurses is managing patients whose conditions may require multiple changes in orders in a short period of time," she explains. "While staff members may get verbal orders for changes in the care plan, the system is not always in place to quickly transmit this information into a written order.
"Home health patients may also be seeing multiple caregivers if they are seeing different nurses or therapists for different visits," Popovich says. "A physician may give a verbal order to one caregiver, but that order may not make it into the chart as a written, signed order prior to the next nurse or therapist's visit," she explains.
Organizations that are using point-of-care laptops or other technology to instantly transmit a change in an order are complying with this standard more easily, says Popovich. But even with technology, it is important to make sure that someone is reviewing charts on a regular basis to ensure that orders are written and placed in the chart in a timely manner, she adds.
Case managers are the reason that Gibson's agency doesn't have a problem meeting this standard. "Each case manager carries a case load of 20 to 25 patients but she only sees four patients each day," explains Gibson. "The remainder of the case manager's time is spent coordinating care that is given by LPNs, other RNs, or therapists that are seeing the patients," she says. "If medications are changed or if the physician orders a different therapy, the caregiver that receives the verbal order must call and update the case manager on the day the order is changed. This ensures that the case manager can get the order written and signed, and update the medical record to reflect the change before another caregiver visits the patient," she points out.
The case management system works well for several reasons, says Gibson. "The case manager is able to coordinate the larger group of patients because she isn't the only nurse visiting the patient and she does have time during her day to oversee the documentation issues," she says. The system is also beneficial for the other staff members seeing the patient because once they have notified the case manager of the change in orders, they do not have to spend time making sure that the written orders are placed in the record, she explains. "This is a very efficient use of staff and time, and we see that it does keep the patient's plan of care updated more effectively," she adds.
One other standard for which 11% of home health agencies were found non-compliant was HR.3.10, a requirement that the agency assesses a staff member's competence to perform his or her job, points out Popovich. "Agencies across the board struggle with this standard," she says. "Everyone has a program to assess competence developed but it is not always implemented according to the plan developed by the agency."
In many cases, the agency has developed such a cumbersome plan that it is too difficult to implement, Popovich points out. "I always recommend that home health managers take a close look at their competency assessment plan and make sure that they are including only what is really necessary to assess an employee's competence," she says. If you require too much that supervisors or employees don't believe is necessary or appropriate to the job, the assessment won't be performed correctly and the documentation won't be completed, she says.
The Joint Commission doesn't specify what components make up a satisfactory competency assessment so the surveyors have to evaluate the home health agency based upon the program described by the agency, she says. "Keep your competency assessment program simple, straight forward, and directly tied to the job, and this standard won't be difficult to meet."
Sources
For more information about meeting standards, contact:
- Maryanne L. Popovich, RN, MPH, executive director of Home Care Accreditation Program, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5742. Fax: (630) 792-5005. E-mail: [email protected].
- Sue Gibson, RN, director of Midwest Home Health in Del City, 3921 SE 29th St., Del City, OK 73115. Phone: (405) 677-7911. E-mail: [email protected].
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