Tips from a recent survey
[Editor’s note: This column will be a regular feature in Hospital Peer Review profiling a facility that recently has been surveyed by the Joint Commission on Accreditation of Healthcare Organizations. If your facility was recently surveyed, please contact Staci Kusterbeck, Editor, Hospital Peer Review, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: [email protected].]
When surveyors from the Joint Commission come knocking at your door, they will want to see proof of compliance with each one of the six patient safety goals, says Kathy Brandeis, RN, BSN, performance improvement/JCAHO coordinator for Saint Joseph’s Hospital of Atlanta, whose facility recently was surveyed.
"Be prepared to demonstrate how you’re complying with every single one of these," she warns. "They are looking for 100% compliance."
Surveyors quizzed various staff members about each safety goal, including hospital board members and surgeons, she reports. For example, surveyors asked, "What do you do before you give a medication or before you draw blood?" In this case, they wanted to see that staff knew to check for two patient identifiers, and asked what they were, then looked to see if other staff were really doing this, says Brandeis.
Surveyors wanted to see that a time-out is done to verify correct patient, procedure, and site, and that this is documented in the chart —not just for surgery, but for any invasive procedure, such as putting in chest tubes, she says.
Here are other areas of focus during the survey:
• Health status of physicians.
The physician surveyor asked about the facility’s policy for assessing the health status of physicians, says Brandeis. "There have been new standards related to that in the past couple years, and they are looking to see how they have been incorporated." For example, the surveyor asked about the process that occurs if an impaired physician is identified.
"They really want to know how the process is done and that it encompasses all that is required," she says.
• Infusion pumps.
Surveyors asked about the process to ensure that all PCA and infusion pumps are free-flow protected, says Brandeis. "Make sure you have your biomedical person in that interview. At our facility, he spoke to the surveyors about how he had written the company and ensured that these pumps are free-flow protected, and also explained our process for this."
It was explained that for the facility’s hyperbaric unit, free-flow protected pumps cannot be used, says Brandeis. The surveyor was informed of the following triple-check mechanism to ensure that the infusion pumps do not leave the hyperbaric unit:
— A red plate on each pump says, "This machine is not free-flow protected and may not leave hyperbaric unit."
— Each pump has a serial number and has to be accounted for every single morning.
— If a pump is needed in another unit, the facility’s policy states that another pump should be obtained from central supply, instead of borrowing one from the hyperbaric unit.
• Infection control.
Surveyors wanted to know the process for keeping track of which scopes were used for which patients, says Brandeis. Each scope is numbered, and this is tracked electronically in the OR, and manually documented in other areas.
"On your documentation sheet, you already have the patient’s name, medical record number and findings, and you can just add, Bronchoscope #1,’" she advises. "Writing down serial numbers is too long, and you can make mistakes."
• Medications.
In the OR, surveyors wanted to see the system used to account for all narcotic and medication use, says Brandeis. "That is a biggie, because there have been cases of anesthesiologists misusing narcotics."
The surveyor observed anesthesiologists returning narcotics to pharmacy and were looking for a double-check mechanism to see that whatever was not used actually was brought back, she says.
• Failure mode and effect analysis (FMEA).
"You better have a hospital board member present when you are developing this, and they need to be involved in the grunt work — the actual process of writing it," says Brandeis. "Many people really hadn’t done that." Fortunately, the facility’s pharmacy and therapeutics director was a member of the hospital board at the time of the survey, she says, and for the current year, a surgeon who is a board member will participate with the FMEA development.
• Documentation.
Surveyors checked that physicians documented that they have informed the patient of the alternatives, risks and benefits and that the patient has agreed to the procedure, says Brandeis.
"The patient can sign the consent form, or the physician can document this in the history and physical or in their progress notes," she says. "They cannot document it in the operative report because that is after the fact."
[For more information about the facility’s recent Joint Commission survey, contact:
• Kathy Brandeis, RN, BSN, Performance Improve-ment/JCAHO Coordinator, Saint Joseph’s Hospital of Atlanta, 5665 Peachtree Dunwoody N.E., Atlanta, GA 30342-1764. Telephone: (404) 851-7506. Fax: (404) 851-5604. E-mail: [email protected].]
Editors note: This column will be a regular feature in Hospital Peer Review profiling a facility that recently has been surveyed by the Joint Commission on Accreditation of Healthcare Organizations.
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