JCAHO surveyors focus on flow, competencies
Nurses answer detailed questions on safety
When the Joint Commission for Accreditation of Healthcare Organizations surveyed McKay Dee Hospital in Ogden, UT, surveyors focused on something that ED nurses did not expect: competencies of agency staff.
"We only use them in a blue moon, a couple of times a year, but this was a major focus," says Teri Howick, RN, nurse educator for the ED.
Surveyors asked, "Just because the agency says they are certified in advanced cardiac life support, how do you determine they are competent?"
"They feel that the individual needs to be observed," says Howick. "No amount of paperwork can reassure them." Surveyors recommended that this observation be done before the agency nurses are used in a clinical setting, but this is difficult if no one is qualified to observe them, such as the technician who runs the lithotripsy machine, notes Howick.
"They weren’t happy with the current practice and would prefer they be observed," she says. "But the nature of an agency person is that you don’t have enough staff to cover your shift. How then, are you going to observe them?" The issue has yet to be resolved, Howick adds.
Surveyors also were interested in patient flow, and they liked the electronic tracking system used to identify reasons for admission delays. "We now know if the room is delayed because it’s being cleaned or patients are being moved. That helps us because we can track trends," says Howick. "If we can never get a patient upstairs from 11 to 2, that tells us they are not staffing well enough for lunches."
Surveyors also looked at door-to-doctor time and average time spent in the ED, and they asked nurses to explain patient flow for specific patients whose charts were pulled, says Howick. "They looked at the whole flow continuum and where the delays are," she says.
After reviewing the nursing notes in patient charts, Joint Commission surveyors asked specific questions such as, "Why did you place your patient on a monitor?" "Why did you put in a Foley catheter?" "What did you do to assess your patient initially? "What did you deduce from your assessment?" and "How often are you planning to check on your patient and what are you assessing for when you do check on her?" recalls Laurie Brown, RN, an ED nurse. "They also checked the doctor’s sheet against my nursing notes," she adds.
Surveyors watched staff to see if hand sanitizers were used. "We went through gallons of it," says Howick. "We had a cardiac alert where our goal is door-to-cath lab time of 30 minutes, so people were going in and out of the room like crazy. I probably Avagarded my hands 20 times in 10 minutes," she says.
Here are other questions asked of ED nurses by surveyors:
• What sentinel events have occurred, and how were they addressed?
"Previously, in most facilities, these things were looked at in a negative light. If something bad happened, it was kept quiet," says Howick. "Now the rationale is to let everyone know about the problem and take proactive steps to correct it."
Nurses told surveyors about an incident in which a psychotic patient hooked his intravenous line to his pneumatic blood pressure, which could have been dangerous because both had Luer locks. They explained how the adaptations were changed to reduce the risk of injury.
"We also tightened our observation of confused and psychiatric patients," says Howick.
• How are errors reported?
Nurses explained the process, beginning with a compute- generated event report that goes to the risk management team for review. The team’s recommendations are reviewed by the clinical practice council so system changes can be implemented as needed, says Howick.
• If somebody called and asked if a patient was in the ED, how would you respond?
Surveyors were looking to see that nurses were complying with patient privacy regulations, says Howick. Nurses replied that unless the patient has requested that their name not be posted, the caller can be told that the patient is at the ED but cannot be told their complaint.
• How do you ensure that nurses are competent?
Previously, nurses attended a skills lab with a written test afterward, says Howick. "But to me, that didn’t mean that they were competent — just that they had showed up," she says. Howick now does one-on-one observation to observe skills such as setting up a Level 1 infuser or electrocardiogram recognition, until she’s confident that the nurse is competent. "It’s pretty time-consuming, but the surveyors liked that process," she says.
• How do you know what time a medication was ordered and given?
Surveyors were focused on the timing of orders and wanted to see that nurses had given medications in a timely fashion, says Pam Lindley, RN, a staff nurse at McKay Dee’s ED. "We had a physician order with no time documented, but the nurse had meticulously charted serial assessments for pain, when she notified the doctor, and when she gave the meds," she says. "They were trying to push the responsibility on the nurse, but it’s a doctor issue to time their orders."
The physician can verbally order a medication but must then write the order on the chart and time stamp it, or write in the time ordered, Lindley explains. "This new process is more logical and gives a better picture of the care the patient received," she says.
[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 recent Joint Commission survey, contact:
- Laurie Brown, RN, Emergency Department, McKay Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. E-mail: [email protected].
- Teri Howick, RN, Nurse Educator, Emergency Department, McKay Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-2286. Fax: (801) 387-2244. E-mail: [email protected].
- Pam Lindley, RN, Emergency Department, McKay Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. E-mail: [email protected].
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