Surveyors look at newborn security, staff competencies

Hospitals get big star for FMEA

Has your organization ever conducted a "Code Adam" drill, which simulates how staff would respond if there were an attempt to abduct a baby from the obstetrics ward during a fire drill?

This question was asked of staff at Valley Regional Hospital in Claremont, NH, during a recent survey by The Joint Commission. "I thought it was a great question," says Sandy Gee, quality improvement director. "I found it very intriguing. We hadn't really thought about it but I understand the reasoning for it. A perpetrator could pull an alarm to distract the staff."

Surveyors looked closely at security systems on the hospital's maternal child health unit. They asked whether staff had ever caught the perpetrator during a Code Adam drill, and what improvements had been made as a result of previous drills.

Nurses explained to surveyors that after a recent drill, the alarm systems were changed. An audio and visual flashing light was added in the admitting area as a visual signal; since other alarms go off in that area, this would be a clear warning that could not be overlooked.

The nurse surveyor looked at staff competencies during every patient tracer. After asking a patient's diagnosis in the behavioral health unit, she asked how the nurse did the medication reconciliation process, the history and physical, pain assessment, and assessment of vital signs. She also asked, "What are you doing as an individual and as a team to treat the patient? How often is the treatment plan updated? How is patient education done?

"Then she asked the case manager about her skill set and her competencies, asking how she became competent to work in that particular area," says Gee.

While the surveyor was observing a nurse giving a medication to a patient, the patient spit out the medication and refused to take it. "The surveyor was pleased to see that the nurse listened to the patient's concerns, and went back and clarified the order with the physician," Gee says.

The surveyor asked if the treatment plan was multidisciplinary, and also wanted to know the process if the patient wanted to bring in their own medications, and whether those medications needed to be cleared by pharmacy. The survey team was impressed that the hospital was one of three hospitals in the country with the largest improvement in patient satisfaction, which won them the Press Ganey Compass award. "During the leadership session, we were able to describe how we had made progress," says Gee.

FMEA on patient ID

Quality professionals proudly described several improvements that were made as a result of core measures and Institute for Healthcare Improvement initiatives. However, surveyors cautioned that internally identified areas should not be overlooked. "They said all the outside initiatives were wonderful, but that we need to make sure that we continue to focus on our hospital," says Gee.

Staff reported on the Failure Mode and Effects Analysis (FMEA), which was done on patient identification. This FMEA addressed every single area of the hospital, including same-day surgery, the emergency department, and maternal child health, to ensure that consistent approaches were used. "The surveyors particularly liked the topic of patient identification as an FMEA," says Gee.

Several changes were made as a result of the FMEA, such as one department's adding the patient's date of birth to labels that previously only listed the patient's name. On another unit, staff were in the habit of handwriting patient information on labels, so printers were purchased to eliminate the chance of human error.

Procedures for patient identification were tightened in physician clinics and outpatient areas. "Sometimes you are so focused on acute care, and clinics may not undergo the same scrutiny," says Gee. "We wanted to ensure that staff were using the same two identifiers for medication administration."

Critical test results reporting also was looked at during patient tracers and discussed during the data use session. "The surveyor saw critical test results on a patient's chart, and asked about the process and whether there was a specific time frame they needed to be reported in," says Gee. "They also asked what the next step was if the nurse didn't get an answer from the provider."

Surveyors asked how compliance with hand hygiene was measured and offered the suggestion of using a "secret shopper" methodology. "Of course, if the nurse sees the infection control officer, she will make sure to be compliant," says Gee. The surveyors suggested having a nurse or housekeeper observe to see if staff practice hand hygiene. "We currently use the secret shopper methodology to observe medication administration, to ensure that staff follow the correct steps," says Gee.

[For more information, contact:

Sandy Gee, Quality Improvement Director, Valley Regional Hospital, 243 Elm Street, Claremont, NH 03743. Phone: (603) 542-3414. E-mail:]