ED Accreditation Update: First EDs to undergo regular unannounced surveys warn: Be prepared for questions
ED Accreditation Update
First EDs to undergo regular unannounced surveys warn: Be prepared for questions
It’s after lunch, and your volume is peaking. You think things can’t get any more hectic, but here come accreditation surveyors visiting your department as part of an unannounced survey.
It’s show time.
The Joint Commission on Accreditation of Healthcare Organizations began conducting all regular accreditation surveys on an unannounced basis beginning in January 2006. As ED managers go through the first regular unannounced surveys, they are reporting that they and especially their staffs are heavily involved in the process as inpatients are traced back to the ED and staff are questioned about how standards and National Patient Safety Goals are addressed in the ED.
To ensure you and your staff aren’t caught off-guard, consider these suggestions:
• Be part of a notification system, and use a last-minute checklist.
When the surveyors arrive at your door, have a system in place for being notified and notifying your staff, sources suggest. At Baylor All Saints Medical Center at Fort Worth (TX), surveyors arrived at the hospital’s information desk, and a general overhead page went out over the intercom system that said, "We’d like to welcome our guests, the Joint Commission surveyors."
The ED staff knew what to do, recalls Susie Hood, BSN, RN, CNRN, director of emergency services. "They went into high gear and did a last-minute checklist," she says. (See checklist.) For example, staff made sure the front and back of each page of each patient’s chart had a patient identification sticker on it.
Hood e-mailed the director of the local ambulance vendor to notify their staff about the visitors, Hood says. Employees of the emergency medical service were on their best behavior, and one shift relayed the information about the survey to the next shift, she says. "It’s helpful for any outside vendor to know."
• Know that patients may be traced back to the ED.
Patient flow through the entire organization is a strong emphasis of the Joint Commission, says Darlene Christiansen, RN, LNHA, MBA, executive director of accreditation certification operations at the Joint Commission.
"We’re looking at the whole process of moving the patients through the continuum of care so the ED doesn’t become a bottleneck with the organization, so they flow through the process appropriately," Christiansen says. That focus means the ED is often part of the tracer methodology used by surveyors, she adds.
Surveyors select patient tracers based on the hospital’s priority focused areas, which are determined by the diagnoses and care levels at the facility, Christiansen says. The tracer process includes a review of the staff’s level of expertise, their orientation, and their education, including instruction on new processes and protocols, she says.
At Aurora Healthcare System in Milwaukee, the tracer methodology differed significantly from previous surveys at Aurora’s hospitals at which there would be a dedicated reviewer and a focused review of the ED’s policies and procedures, operations, and staffing, says Rebecca Long, regional director of emergency services. Those past reviews lasted more than an hour with an emphasis on documentation and answering questions, she says.
This year, almost three years exactly since their previous survey, the surveyors traced some inpatients back to the ED, where they entered the system, she says. The surveyors wanted to talk to staff, physicians, and even clerical staff, but no managers, Long says. They were quizzed on areas such as the practice for transferring patients to another hospital and how they managed patients using conscious sedation, she says.
Baylor All Saints also saw patients traced to the ED, and the surveyors arrived at the department’s peak time. "We were full and scrambling," Hood says. "They said, We’ll just talk to the director.’ I thanked them for not interrupting patient care."
Instead of being asked about the tracer patient, the surveyor asked Hood how her department handled look-alike, sound-alike drugs. She showed him the ED’s automated medication distribution station, and she showed him how the policy on look-alikes, sound-alikes had been laminated and posted on the machine. "He had me open the Pyxis to show him that they were stored nowhere near each other," Hood says. "They were in totally separate drawers."
An administrative surveyor traced a stroke patient to the ED, she says. "That was very fortuitous for me because my specialty has been neuro," says Hood, who serves on her facility’s stroke team. The surveyor had conferred with the physician surveyor, and they wanted to know why an MRI was delayed until morning rather than using the test to determine whether there had been a stroke and to identify the type of stroke, Hood says. "Most of my interview was educating the surveyor on the difference between a CAT vs. an MRI in the initial stroke process," she says. "He even said on his daily synopsis that I had spent more time educating and grilling him than he did me."
At Aurora, an Urgent Care Center had just opened, and the surveyors visited it, Long says. "We were in the process of transferring a patient to an ED," she says. "They asked, What is your policy around transfers?’ and said, We want to see your forms.’"
• Expect emphasis on National Patient Safety Goals.
In terms of the patient safety goals, the surveyors want to ensure that EDs are meeting the goal that requires, when possible, the read-back of verbal orders, telephone orders, and critical test results by phone. A read-back is not appropriate if a patient needs urgent care and there is no time to read back the order, Christiansen says. However, in some cases, patients may be stable and be held in the ED prior to admission. "At that point, some of the criteria for the National Patient Safety Goals, such as the read back process, apply," she says.
At Baylor All Saints, a surveyor asked how critical lab values were read back, and then he questioned other staff to determine consistency, Hood says. He also asked to see the quality data to see consistency with practice, she says.
Also, surveyors put a "huge" emphasis on the goal regarding hand off communication, Hood says. "They asked how we got reports from the field," she says. Hood explained the entire communication process, including how ED nurses turn over patients to inpatient nurses. "They wanted to see that we had standardized hand off communication through the hospital," she says. While the ED handoff will be different than the inpatient side, there must be consistency, Hood says.
At Aurora, the survey was overall more user-friendly than in the past, Long says. "In the past, it felt much more regimented; this was much more free-flowing," she says. "You never knew where they would be or what they would be doing, but they tried to really understand what we did."
Source/Resources
For more information on unannounced surveys, contact:
- Susie Hood, BSN, RN, CNRN, Director of Emergency Services, Baylor All Saints Medical Center at Fort Worth, 1400 Eighth Ave., Fort Worth, TX 76104. Phone: (817) 922-1290. E-mail: [email protected].
You can find out whether the Joint Commission on Accreditation of Healthcare Organizations is visiting your organization that day by checking the Joint Commission’s extranet web site. At 7 a.m. Eastern Standard Time, the site will tell you if today is the day and will provide surveyor biographies. Go to www.JointCommission.org and go to the “Jayco login” section. Then click on the “notification of scheduled events” link.
The Joint Commission also offers several free resources on its web site (www.jointcommission.org/AccreditationPrograms/Unannounced_Surveys.htm.) Those resources include a telephone conference call replay and transcript, two presentations, and questions and answers.
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