Surveyors look closely at patient flow, patient safety
During an unannounced survey at Baptist Hospital of Miami, surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) asked to come in the front door of the ED and follow the triage process, to be certain that patients were treated without regard for their ability to pay.
"They asked clerks about that and instructed the rest of us not to speak," says Becky Montesino, RN, ED nurse manager.
This set the tone for the "very intense" survey, she says. "I expected a survey of the old, when they would go into a trauma room and open a drawer," Montesino says. "They didn’t do that type of thing." They were centered on patient safety, she says.
The surveyors are very knowledgeable, Montesino says. "They do a lot of teaching," she says. "And they know very early on in the survey where your strengths are and what they need to validate."
However, nurses were just as ready to demonstrate as the surveyors were eager to observe, says Penny Bromberg, RN, an ED staff nurse. Hand washing was highly scrutinized, Bromberg says. "One of the surveyors shook the hand of a technician, who immediately washed her hands in front of the surveyor, and I understand they were quite pleased," she says. "We have soap-free lotion easily accessible to staff members wherever they find themselves in the department."
Here are key areas of focus during the survey:
• Patient flow.
"They took the new JCAHO leadership standard of overcrowding very, very seriously; it was at the top of their list," says Montesino. "They commended our hospital in facing its challenges with our volume and ED crowding and for thinking out of the box for solutions."
For example, surveyors liked that a report went out twice a day to inform leadership how many admitted patients are waiting for a room "so everybody knows if the ED is in trouble," says Montesino.
Surveyors wanted to know how patient flow was optimized for all types of patients, including patients held in the ED or those treated and discharged. They evaluated flow during patient tracers by interviewing staff and making frequent tours to the holding areas, Montesino says. "If patients are held, they want to know that there is no change in the standard of care, period," she says. "This is the key. They never quit on this, to the last conversation we had with them."
This same standard of care for patients being held means appropriate documentation of pain assessment and reassessment, providing privacy for patients in hallways, and ensuring that patients get meals while waiting in the ED, says Montesino. Surveyors suggested patients held in hallways should be given pajama bottoms in addition to standard hospital gowns, she adds.
The surveyors liked that the ED designated several rooms as in/out exam rooms, Montesino says. "So if patients are waiting in the hallway and all their tests are back, they can go back to a room while waiting for the final disposition from the physician," she says. "We also have a treatment room or two set aside so the patient has private time with the ED physician, even if they are going home."
During the week of the survey, the ED’s volume of admitted hold patients was at an all-time high, so Joint Commission surveyors were alerted that the ED was going into a "surge plan."
"They were amazed that we could pull it together that fast," Montesino says. "And they didn’t miss a trick; all the surveyors looked at the 12 patients who were moved out of the ED and made certain that their tests were timely, pain management needs were met, and that there was good communication from ED to that holding area."
• Mode of arrival for all patients.
It was important to document the patient’s mode of arrival, says Montesino. During one patient tracer, the surveyor went to one of the organization’s urgent care centers and waited until a patient was transferred by ambulance to the ED. He continued to follow the patient until he was admitted, Montesino says. "I think most EDs can expect that to happen," she says. "It seemed to be a well-oiled process."
• Use of verbal orders.
"We have done extensive education for our read back program," says Montesino. "When ED nurses get telephone orders from admitting physicians, they document orders read back.’ Surveyors observed to see that the orders were actually read back."
[Editor’s note: If your ED was recently surveyed by the Joint Commission and you would like to be featured in an upcoming ED Nursing article, please contact Staci Kusterbeck, Editor, ED Nursing, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: [email protected].]
Sources
For more information on the accreditation survey, contact:
- Penny Bromberg, RN, Emergency Department, Baptist Hospital of Miami, 8900 N. Kendall Drive, Miami, FL 33176. E-mail: [email protected].
- Becky Montesino, RN, Nurse Manager, Emergency Department, Baptist Hospital of Miami, 8900 N. Kendall Drive, Miami, FL 33176. Telephone: (786) 596-4489. E-mail: [email protected].
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