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ED joins hospitalwide effort on survey findings
More often than not, ED managers and their staffs toil in relative anonymity as they go about their daily work. However, once the recent findings of a survey by The Joint Commission at Boston's Massachusetts General Hospital (MGH) were made public, that was no longer possible.
The staff learned in late 2006 in a memo from MGH's CEO Peter Slavin that "we did not do as well as we should have, and that there were a number of areas we just had to get to work on," notes Greg Meyer, MD, MSC, medical director and vice president of quality and safety for the Massachusetts General Physicians' Organization. "When you have 20,000 employees, you know that e-mail is going out in the public domain."
And go out it did, in the form of coverage by The Boston Globe. Slavin's memo was cited in the paper as saying The Joint Commission found employees weren't washing their hands enough, weren't completely filling out medical records, and weren't correctly following medication reconciliation policies.
MGH chose to respond with a policy of total transparency. Today, anyone who wishes to know the full story can go to the MGH web site, www.massgeneral.org, and click on the link on the left-hand side of the home page that says, "Massachusetts General Hospital Joint Commission Findings." Once there, the reader will see a letter from Slavin and an MGH summary of the Joint Commission findings. In each case, it enumerates what was found, why it was important, what MGH is doing about it, and what progress they have made to date. And, for those who care to wade through it, The Joint Commission's final report also is there in its entirety at the bottom of the page.
ED gets involved in process
ED management and staff were informed of the survey findings in that memo from Slavin. As strategies to respond to the findings took shape, there were no specific comments aimed at the ED or other departments.
"Because the [response] process is hospitalwide, this was not an ED-specific thing; we were all part of the solution," says Mary Fran Hughes, RN, MSN, nurse manager of the ED at MGH. "They told us what The Joint Commission recommendations were, and we looked at what was happening in our area that we could improve." All along the way, she adds, best practices were shared among the various departments at leadership meetings.
There were several areas of emphasis the ED chose to address, recalls Ann Morrill, a staff nurse in the ED whose responsibilities include Joint Commission compliance. One involved reassessment of pain, Morrill recalls. "This is very important to The Joint Commission, and we are very good at it — but not so good at documenting," she says.
Morrill sent an e-mail to the staff to remind them of the importance of documenting. She also conducted random chart audits and provided individual feedback to nurses who were not documenting properly.
This is an old issue, says Hughes, "but the audits showed people the evidence that they were not writing down all their actions." There definitely has been an improvement, she says, although the audits are hospitalwide so exact statistics for the ED are not available. "However, we have a small group of auditors, and they say they can definitely see the progress is there," Hughes says.
Hand washing was another major issue, although Morrill notes it is probably more of a standard practice in the ED than in some other areas of the hospital. In fact, she says, at the time of the survey, the compliance rate was in the "high 80s."
This figure was based on ED-only audits, Hughes says. "Still, we looked for ways to make it even easier for staff to wash their hands," she says.
One of the strategies involved changing the location of the dispensers for the department's antiseptic hand rub, Morrill says. They put them all at the doors for staff to use as they enter the patient's room, she says. "We had them inside the rooms, but we felt that sometimes people went in and did not look at them," says Morrill. "We also put a lot more around the nurses' station; we doubled the number of dispensers."
In addition, says Hughes, three staff nurses were dubbed "hand hygiene champions" and were given time each month to stand in the patient rooms and conduct audits on whether people were washing their hands. "Our scores are much higher — in the mid-90s — and we hope to get to 100%," says Hughes.
Morrill also addressed the issue of abbreviations in documentation. "There are two abbreviations you are not supposed to use in the ED: QD (every day), and MSO4 for morphine," QD can be confused for QID (four times a day), and MSO4 can be confused with magnesium sulfate, she explains. "If you want medicine taken daily, you write 'daily,' and for morphine, you put the full name of the medicine."
Doctors and nurses were using the banned abbreviations, so Morrill created a poster listing all the abbreviations that were not to be used and attached a copy to each computer in the department. "We did a lot of walking around to remind people as well, and we conducted audits, too," she says. "It's definitely getting much better."