Warning! Accreditation surveyors may talk with patient access staff
Get your employees involved with initiatives
Any staff member with patient contact, including those who perform a registration function, might be approached during a survey by The Joint Commission, according to Cynthia Leslie, RN, associate director of The Joint Commission's Standards Interpretation Group.
Lauree M. Miller, director of patient access at Catholic Health Initiatives Nebraska in Lincoln, says, "The perception of patient access was that they just get a name and date of birth. Actually, patient access has a lot of ownership in different Joint Commission standards."
Patient access leaders need to let administration know they want to be involved in Joint Commission initiatives, says Miller. "You don't want to hear it in a memo. You want to be at the table to drive the changes," she advises. "You don't want to be afraid of Joint Commission coming to your facility."
Before the new patient tracer methodology was implemented by The Joint Commission in 2004, Miller recalls, surveyors would ask to see charts from previous months to review them retrospectively. "Now they come in, and they talk to the patient. They say, 'Tell me about the admission process. How were you explained your rights?' We need to be consistent with what the patient is saying," she says.
At Catholic Health Initiatives Nebraska, patient access staff are "very involved" in ensuring compliance with The Joint Commission's National Patient Safety Goal requirement to use at least two patient identifiers, says Miller.
"We start the process by identifying the patient upfront. The clinical staff then validates it, but we need to be involved in that piece," she says.
Staff members need to have a clear understanding of the two identifiers, says John Wallin, RN, associate director of standards interpretation at The Joint Commission. "Some people think that an armband is considered an identifier, but it is not. An armband is merely a source of information," Wallin says. "People need to be clear on that."
If the patient is not correctly identified during the registration process, this problem potentially can lead to a bad outcome, Miller warns. "If we have the wrong date of birth, that can have some negative impacts down the road, since care is sometimes driven by a patient's age," she says. "We have to hold each area responsible for their part in the process, to make sure the patient is safe."
4 items to review with registrars
Melissa R. Almond, patient access team leader at Palmetto Health Richland in Columbia, SC, says the following information is reviewed with registrars to ensure Joint Commission compliance:
completing the patient language field, to ensure that the patient can be cared for appropriately if they are a non-English speaking patient;
asking for information on advanced directives and letting patients know that information on how to obtain living wills and healthcare power of attorneys is available;
obtaining consent for treatment and the assignment of benefits, and making sure that these forms are accessible after they have been signed;
obtaining signatures for the Important Message from Medicare.
"We send out an email blast once a day when we are expecting that The Joint Commission may be coming soon, just to keep it on everyone's mind," says Almond. Take these steps to improve compliance in registration areas:
Ensure patients understand their rights and responsibilities.
At Catholic Health Initiatives Nebraska, an educational folder was created with all of the materials staff members are required to give patients.
"We hand out lots of brochures, but does the patient really understand them?" Miller asks. "You can't go through everything. There is just not enough time. But we have a lot of scripting in place for registrars to cover the highlights of the content."
Staff should be able to articulate their process for informing inpatients and outpatients of their rights and responsibilities, says Wallin. "Staff may think that standards are specific to inpatients only, and that is not accurate," he says. "There are actually very few elements of performance that we even differentiate between inpatient and outpatient."
Protect the privacy of information by speaking quietly, making sure computer screens are not visible to unauthorized people, and not asking for protected health information (PHI) at a registration desk that is within earshot of anyone else.
"Some organizations have established a line with a sign that says, 'Please wait here for the next available receptionist' to create distance, so the audible piece of this is not problematic," Wallin says.
If registrars copy or scan a patient's driver's license or insurance cards, there must be a process to ensure that the paper copy doesn't end up in a waste basket, he adds.
If sign-in clipboards are used in registration areas, be sure that the information you are asking for is not PHI, adds Wallin.
Be sure staff can determine when an interpreter might be needed and how to access those resources.
"When interpretive services are needed, the organization needs to ensure that those serving in that role are competent to do so," Wallin says.
Sources
For more information on how patient access departments prepare for a Joint Commission survey, contact:
Melissa R. Almond, Patient Access Team Leader, Palmetto Health Richland, Columbia, SC. Phone: (803) 434-6782. Fax: (803) 434-7092. Email: [email protected]
Lauree M. Miller, Director, Patient Access, Catholic Health Initiatives --Nebraska, Lincoln. Phone: (402) 219-5488. Fax: (402) 219-8008. Email: [email protected].
Cheryl L. Webster, Director, Patient Registration Services, Beaumont Hospital, Royal Oak, MI. Phone: (248) 898-0860. Fax: (248) 898-3834. Email: [email protected].
Any staff member with patient contact, including those who perform a registration function, might be approached during a survey by The Joint Commission, according to Cynthia Leslie, RN, associate director of The Joint Commission's Standards Interpretation Group.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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