Aid survey preparation with management principles
Use disclosure strategy to change behavior
By Paula Swain, RN, MSN, CPHQ
Swain & Associates
St. Petersburg, FL
It is amazing that well into the 20th year of the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) requirements for a "systematic process to improve care," staff and administrators alike are baffled at what it takes to pass a survey.
Looking at what has happened over those 20 years, one can see that since "quality" has been in vogue we have gone from four studies annually to continuously improving our organizations. The mystique of "survey readiness" disappears when the principles of management prevail, rather than reaction to JCAHO’s notice of survey. Some steps to consider:
1. All standards come into being somewhat gradually. Using the tools of today — the Internet and newsletters that raise awareness — it is easy to test the organization’s status on the new or revised topic and measure it as the topic comes into compliance. New topics such as pain management, patient safety, CPR effectiveness, restraints management, and sedation and anesthesia standards are going to be a focus of the surveyors, and they should be a focus of health care organizations as well.
For example: Pain management issues have evolved from best practices to monographs, from multiple associations to field testing of standards, and finally to standards with a year of lead time. Because the surveyors had been educated on how to score them, many sites had advanced practice in how to structure programs. In turn, those facilities have been sharing this information in journals, survey findings that are posted on listservs, and on assorted Internet sites.
So, to keep an organization ready, use the management strategy of disclosure to examine and change behavior.
- Ask a few burning questions of patients, such as "What didn’t we tell you that we should have about pain?"
- Examine medication practices that are considered the standard in pain management. For example, does the organization use Demerol or morphine?
- Test the staff’s perception of pain by using vignettes and reliability-tested surveys from the Web site www.cityofhope.com.
- Examine a few medical records to see if pain management is anticipated through a protocol or plan of care or reacted to by a patient complaint.
Armed with the organization’s own information, compare how it measures up against the standards. Ask senior management to initiate a new indicator organizationally about the topic under review so it can track the organization’s compliance to the topic. In this case, the baseline for pain management methods could be any of the data listed above, or the answer to the question asked throughout the organization, "Are patients comfortable?" All subsequent data collection and analysis will be dedicated to answering that question.
Going through the management steps of awareness raising, examination of the organization, and creation of an action plan and a measure that can be seen monthly, is the best and only effective method of dealing with JCAHO’s new or revised standards.
2. Communication vertically, laterally, and across disciplines is essential. The entire survey process links together the organization’s ideas, solutions, and care practices. The initial hour of the survey tests this concept. Set the stage using examples that the staff have reported as "important changes." An organization can have projects compete for "best communicated" by testing what staff perceive as the biggest change, not the board of directors’ idea of change. If the first hour of the PI interview does not line up with what the surveyors will hear in later interviews, a disconnect will be identified.
For example: If a policy about patient rights, which is under scrutiny from both JCAHO and HCFA, is not discussed the same way throughout the organization, the surveyors can easily see that not everyone is involved in that process. To be sure that everyone is in sync regarding the organization’s stand on topics, there needs to be a planned method for that to occur.
Policy distribution is an area where standardization of thinking occurs. If policies are just cast throughout the organization, it is likely the manager filter will determine what is essential for the staff to know. For example, in nutritional screening, this particular situation occurred. There were screening criteria set up in the organization to refer patients for nutritional needs "when appropriate." Because the inpatient was thought to be the focus, no one thought about the outpatient, lactating mother in the clinic setting or emergency room when she was given antibiotics for her infection.
The "manager filter" did not pose anything beyond the policies that were presented, yet nutritional screening was appropriate in these settings. That is true with abuse screening for violence against elders and children, and domestic violence in either sex.
"How can this policy apply to my staff?" is a good question to ask before dismissing a policy as "not for me." When considering that, think beyond assessment and consider the reassessment standards as well. A patient’s condition can change throughout the stay and between visits.
Because everyone in the organization is asked questions about policies that relate to JCAHO standards, communication through a team or staff meetings with designated departments sharing information is critical.
Have all policy-makers define on a cover sheet, "who the policy is intended to affect." Also include how the policy-makers will know when the change has been institutionalized and what measures will be used to determine if those departments got the message as designed.
Now when the staff throughout the organization are polled as to the biggest change, management will see the effectiveness of their methods to diffuse information.
3. Integration in all communication processes is vital. Besides the leadership (LD) standards that demand integration in LD.3, the surveyors see integration expressed most prominently in the unit interviews, chart reviews, and time spent in dialogue with staff. It’s a good attempt at integration to write many departmental names on policies and protocols, but it is all fluff if the unit meetings that discuss patient care don’t see evidence of group management of the patient.
Some situations show how little integration there is when an amputation patient who shows evidence of a heart attack is put in a critical care area and physical therapy is never visible in the record. Or when a dietitian makes recommendations because a patient’s lab values are out of whack, her calorie counts are too low, and a diet change is needed, but the physician never takes note of the findings, and there are no comments why or follow-up from nursing to pursue this nutritional situation.
These situations can be avoided by using a few key words that are problem-oriented and negative, such as or "severe iron deficiency" or "lack of mobility." In this case, the whole team could rally around the patient’s "poor nutrition," and the amputee could have a focus in his care of "lack of mobility." Then all the interventions staff are doing would dovetail, and upon querying each service, they could tell what their contributions are for each problem or issue.
In the past, this concept has been known as a "care plan," but usually there is emotion and disregard associated with this concept. However, patients get better in a shorter period of time if there is a way to center care. Look at the effectiveness of care paths and standardization on protocols and guidelines. These are all tools that lend to integration. Surveyors expect this.
It is sad to get a group of care providers together and see them hoard their notes in notebooks that go to the basement with them at day’s end, while the unit housing the patient has no idea what the plan is. Also, as a surveyor prepares to query the team, a singular question is asked: "Can you tell me about this patient from your perspective."
In those sessions, the disclosure may be that the staff member had no idea the patient came from a higher intensity of service, or had a pacemaker, or was on a complex, high side effects type of drug. If the organization has no way to centralize care, a simple question such as, "what is the patient’s favorite food?" will be a nail in the coffin of integration.
Check to assure there is a problem to manage. The management features of health care are done from the patient bedside to the board room. That’s the point of getting everyone involved; if a high census should take a key player away, someone else should know how to step in.
Examples of management are found in the interdisciplinary documents that meet JCAHO standards like patient education and assessment. You will have arrived in the eyes of the surveyors if a "control panel" document such as a patient education form is present in the record that:
- shows education from preadmission through discharge;
- has an entry at least daily;
- demonstrates many types of providers contributing to the patient’s education.
Plus, the organization can defend its practice of interdisciplinary communication and its grasp of the standards when this form is filled in and provides guidance to the group caring for the patient. The true gold medal documentation test would be to see a service such as respiratory therapy reinforcing a prior entry on the education document by dietary regarding calories required in the food prescribed to sustain the exertion required for the patient to increase his respiratory tolerance.
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