At this agency, survey preparation never ends
Infusion provider doesn’t rest on laurels
Your agency just earned the Joint Commission on Accreditation of Healthcare Organizations’ highest accreditation standing. You received a whopping 100% on your JCAHO survey. What’s next?
If you’re Susan Eaton, branch manager of Coram Healthcare in Bakersfield, CA, you turn right around and start working toward your next survey.
At Coram, a home infusion therapy provider, quality improvement is a continuous process that doesn’t stop once the surveyor leaves. Even a perfect score leaves room for improvement, since standards keep rising. And maintaining a high level of quality care can be difficult, with staff turnover and a very human tendency to relax once the immediate pressure is off.
"What you could do is backslide," Eaton says. "Getting 100% was fantastic and it made everyone feel wonderful, but it does not necessarily mean that you’re going to get 100% next time unless you do the same kind of work and effort that you did before."
Get on the grid
Eaton has been at Coram’s Bakersfield branch for three different JCAHO surveys. In each, the agency did well, scoring above the 95% mark.
The system put in place for past surveys remains in use today, to help managers keep a constant watch over the operation.
Coram’s corporate office devised a grid system — basically a checklist that included every point that Joint Commission surveyors would be examining, as well as other standards the company wanted to ensure in branch offices.
In the area of branch administration, for example, grid tasks would include annually verifying the licensure of all clinical personnel, posting an updated organizational chart, updating all operations manuals, and compiling a sample patient packet.
In human resources, tasks could include checking to be sure staff medical records are kept separate, employee applications are in their files, and that continuing education hours are up to date.
Tasks throughout the agency can be as minute as checking the operation of fire extinguishers — anything a surveyor could conceivably check.
On the grid, Eaton can fill in the date a task is completed. If it’s not complete, she can note who is responsible for handling it and offer a brief action plan for getting the it done.
The long list of tasks is apportioned out to the appropriate departments to fulfill. A team, composed of the pharmacy manager, nursing manager, warehouse or operations manager, and admissions representative, helps oversee the effort.
Checks can be made on a monthly, quarterly, or biannual basis, depending on the importance of the task.
"We need to be working on it all year long to make sure that we’re up to speed," she says. Basically, if you do everything on that grid, then you’re doing everything right."
Prior to the branch’s perfect JCAHO score in 1997, it posted a still-impressive 98% in 1994.
While Eaton notes that the agency was doing well in the area of documentation, one issue did arise from that survey, involving the patients’ medication profiles.
"A nurse may have gone to a person’s home and noted that the person is taking Bayer aspirin three times a week in her nursing notes," Eaton says. "But maybe the pharmacist didn’t know that, and on his medication profile he’d have Tylenol and Advil, etc., but not Bayer. It’s in the patient’s chart, and it’s fine that the nurse writes it, but it also needs to be in the medication profile so someone can come in, look at the medication profile, and see everything that the patient is taking."
After that survey, the agency focused specifically on improving those profiles, ensuring that they were updated every time there was a medication change.
That focus was reinforced by regular auditing of charts. Eaton says the nurse manager pulls charts at random every month to review them for accuracy, both from a nursing and a pharmacy standpoint.
If something is missing that can be obtained, it’s added to the file. If the missing item can no longer be added, the manager holds a training session to remind staff of future visits.
Continual inservicing is also vital to keep staff up to date with new requirements. The most important goal in documentation, Eaton says, is establishing a flow that extends from one visit to the next.
"Anyone should be able to pick up that chart and know what’s going on with that patient," she says. "The thing they don’t want to see is someone noted six months ago that the patient has, say, decubitis on the foot and six months from now, there’s no record of what happened to that. It’s all a work in progress."
If the agency finds that staff haven’t consistently been providing some needed documentation, it’s important to show a correction has been made and that compliance is consistent from that point on.
"They [surveyors] do take that into account," Eaton says. "You’re learning and then continuing on."
Even with the principles of continuous improvement in place, the year just before a JCAHO survey still requires a ramping up of preparation efforts. Eaton says her agency is due for its next survey in the first quarter of this year.
How does she look for improvement potential when she’s working from a perfect score? By focusing on areas in which the Joint Commission has raised the bar by strengthening its requirements.
"It’s just much tougher now," Eaton says. "Things they didn’t necessarily look at before, or things they did look at where you had a little bit of leeway — you have no leeway now."
Any new areas are added to the grid and those responsibilities delegated.
In addition, Eaton provides lots of opportunities to prepare staff members for what for some could be a nerve-wracking time. A surveyor may question them individually about their qualifications and about agency procedures. Someone may accompany a nurse on a home visit to see how she interacts with patients.
Practice eases fear
The way to overcome fears and anxieties about the coming survey is to ensure staff are well-prepared with lots of practice questions, Eaton says.
"I think people get really nervous and anxious when they’re not well-prepared, when maybe they’ve only been working in the last two weeks or month to get everything done," she says. "You need to start well in advance and keep it going."
Practice can come at regular staff meetings and other gatherings, to get staff used to answering such questions as, "What is your responsibility in the disaster plan?" or "Who do you go to if you have a problem?"
Eaton says staff should know that this is a rehearsal for the survey so they become familiar with answering the questions. "It’s not that they don’t know the answers, but sometimes when a stranger asks them, they get nervous. This increases the comfort level for them."
As the survey nears, Eaton also compiles a binder to give to the surveyor that contains most of the general information she knows will be asked for — a disaster-preparedness plan, a sample of the admissions packet, employee names, and after-hours phone numbers.
Many of those documents are required to be posted, but Eaton says the binder makes it easier for the surveyor to find them quickly.
"They can still see that they’re posted, but they can look at all the information in one spot instead of making them go track it down. It saves them having to get up every 10 minutes to go find something, and it looks like we’ve done our homework too. I believe in making it real easy and comfortable for them being in the branch."
And once the surveyor leaves and everybody breathes a sigh of relief, what happens? It’s back to work to get ready for 2003.
"Time goes by so fast," she says. "We had our survey and now we’re up again. You just don’t realize how fast the time goes."
• Susan Eaton, Branch Manager, Coram Healthcare, 3101 Sillect Ave., Suite 109, Bakersfield, CA 93308. Telephone: (661) 325-8326. Fax: (661) 325-6509.
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