Unannounced survey takes its toll on ED — Will you be ready when it’s your turn?
Hospitals’ accreditation endangered, EDs partly to blame
In March 2005, seven representatives from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) made a surprise visit to Methodist Hospital in Gary, IN. During the unannounced visit, surveyors reported an overcrowded ED with patients whose needs should have been tended to more quickly.
That is a violation of standard LD.3.11, which requires that all patients admitted but being held in the ED receive the same level of care as inpatients. During the same month, another group of surveyors found more than a dozen violations at Good Samaritan Hospital in Puyallup, WA.
Among their findings: An initial assessment of an ED patient was not performed for more than 24 hours after coming into the hospital.
Following preliminary denials of accreditation, the facilities had until June 30 to respond to the charges. Both hospitals filed written responses with the Joint Commission: Methodist was informed the final decision would be pushed back to Aug. 30; Good Samaritan was awarded conditional accreditation. At this time, the Joint Commission can:
- determine that Methodist successfully clarified the findings and award it accreditation;
- grant conditional accreditation, with a specified period during which the remaining issues must be resolved;
- uphold the preliminary denial of accreditation.
While observers says such instances of accreditation denial are rare, ED managers may wish to pay more attention to these most recent events — particularly the unannounced survey in Indiana — in light of the fact that unannounced surveys go into effect Jan. 1, 2006. For the first three years after that date, you will be told in what year your survey will occur; after that time, there will be no advance notice at all. And while conscientious ED managers no doubt seek to stay within compliance year-round, they no longer will have the traditional six-month period to ramp up in preparation for their survey.
What the Joint Commission will look for
In light of this new reality, and because the Joint Commission from time to time will make significant shifts in the areas of care it emphasizes (i.e., the patient safety initiatives in recent years), it’s important for ED managers to be aware of JCAHO’s latest thinking and potential survey hot spots.
“It’s not always easy to single out a single department such as the ED because of the way standards are written and carry through the continuum of care, but in compliance issues, the patient flow standard [LD.3.15] — which is relatively new — requires leaders to develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital,” notes Pat Adamski, RN, MS, MBA, senior associate director of the Joint Commission’s Standards Interpretation Group.
This standard, which came into play in the aforementioned examples, started as an ED overcrowding standard, she notes.
“One of the ED’s biggest challenges is to identify times of peak demand and [determine] how to handle that influx of patients,” Adamski observes.
While the Joint Commission recognizes that other departments can affect overcrowding in the ED, she says surveyors want to know, for example, if patients are being held at the end of shifts and if they are getting testing done in a timely manner, she adds.
Another hot topic is the issue of patient privacy, Adamski says. “With the way EDs are set up with many cubicles, it’s not always possible to respect the privacy of patients,” she concedes.
More than anything, you must be sensitive to the patient, Adamski stresses. “Most EDs have a couple of rooms with doors; so, if need be, is there a way to get especially sensitive patients into private areas?” she asks.
The final major issue for EDs is the medication management standard (MM.4.10), which requires all prescriptions for medication orders to be reviewed for appropriateness, Adamski says.
“This means whenever an order is written, the pharmacist should review it to ensure there are no contraindications, duplications, or other errors,” she explains.
There are, however, a couple of exceptions to the standard, which can be helpful to such a time-sensitive department as the ED. “If a physician is in total control of the situation — ordering, procuring, dispensing, and administration — we can bypass that pharmacy review,” says Adamski. The other exception, she notes, takes effect if waiting for the pharmacy review could harm the patient. “Since most of what you do in the ED falls under that exception, we just want you to have program in place to do a retrospective review if you skip the pharmacist’s review, to make sure everything was done was appropriately,” she explains.
Surveyors don’t miss much
While JCAHO surveyors may be attuned to specific areas of your ED operation, there isn’t much they will miss, warns Kathleen Catalano, director of regulatory compliance for PHNS, an Addison, TX-based firm that provides information technology, health information management, and business office services.
“When they walk in the door, they will look at everything; they have great peripheral vision,” she notes. “They’ll look to see, for example, if EMTALA [the Emergency Medical Treatment and Labor Act] is posted and in the proper place.”
When it comes to medication management, for example, some EDs have cubbyholes where they stash meds, Catalano notes, “and that’s where the surveyors will look. You’re not supposed to have any meds unlocked unless they are under direct supervision all the time.”
What do you do if a surveyor points out a violation? “I really wouldn’t argue with the surveyor on site if you think they are wrong unless you are absolutely positive,” Catalano advises.
If the citation or finding is based solely on what the surveyor saw in the ED, you have to provide evidence that shows you have corrected the problem and are now in compliance — through a written report, Adamski notes.
While you currently have 90 days to respond, that time will be cut to 45 days on Jan. 1, 2006, she says.
If violations are found, the worst thing you can do is keep your staff in the dark, Catalano points out. “Administration will know about it the minute it happens, but your staff have to be involved because you need their buy-in [for your response],” she explains.
You don’t want to scare the staff, so have a sit-down with as many of them as you can — perhaps even call a special departmental meeting. “Tell them what they found, and be honest,” Catalano insists.
Whatever noncompliance issues have been found, a concentrated effort must be put on those first, she says.
“You have to determine what the best process will be for fixing the problem,” Catalano says. “Make a timeline; rewrite your policy; educate the staff.”
Continual compliance is goal
Of course, every ED manager would prefer to avoid having to respond at all, by being in compliance. Adamski says one of the main reasons for the Joint Commission’s move to unannounced surveys is to ensure just that — and to avoid those frantic six-month ramp-ups.
“We promote being in continual compliance,” she says. Adamski recommends that EDs conduct midcycle self-evaluations to see where they are compliant and where they might need to tighten things up a bit.
She also recommends the Periodic Performance Review, a compliance assessment at the midpoint of the hospital’s accreditation cycle.
Once submitted, the organization has a conference call with the Standards Interpretation Group to discuss plans of action and measures of success for any standards that were found to be out of compliance.
Catalano adds that you should be part of those Periodic Performance Reviews. “Let whoever is in charge of the Joint Commission at your facility know that you want to be part of the survey process and help as much as possible,” she advises. “You should find out what the standards are, what the patient safety goals are, and so forth.”
Not all EDs are so well-prepared, Catalano observes. “As I go around hospitals, ED managers know peripherally what JCAHO wants, but now, with surveyors coming in unannounced, you have to make sure your staff are doing everything right all the time: reading back orders or critical test results, for example,” she says.
If you notice anything amiss, it’s better for you and for your patients that you take a proactive stance, Catalano points out. Then, let the surveyors know what you’ve done, she says.
“It’s very important to blow your own horn,” adds Catalano.
Sources
For more information on unannounced surveys, contact:
- Pat Adamski, RN, MS, MBA, Senior Associate Director, Standards Interpretation Group, Joint Commission on Accreditation of Healthcare Organizations. Phone: (630) 792-5964. E-mail: [email protected].
- Kathleen Catalano, Director of Regulatory Compliance, PHNS, 15851 Dallas Parkway, Suite 925, Addison, TX 75001. Phone: (972) 701-8042, ext. 216. Fax: (972) 385-2445. E-mail: Kathleen.[email protected].
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