Assess patient flow; Use data to improve

That's advice of JCAHO director

The patient flow standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are "about planning," says Carol Gilhooley, director, survey methods development, in the division of standards and survey methods for the Oakbrook Terrace, IL-based agency.

"What we ask organizations to do is assess the flow from admit to discharge, collect data, analyze that data, and turn it into information that can be used to improve performance," Gilhooley adds. "Organizations need to step back and look at [ED overcrowding] as a hospital-wide problem.

"Frequently, there are problems with wait time," she notes. "It could be a problem in the ED, but it might be because of slow discharge and because surgery and the ED are competing for those beds."

JCAHO suggests collecting indicators for key support services to get at solutions that are not the most obvious, Gilhooley says. "Housekeeping may not be turning around rooms fast enough, or lab values may not be coming back quickly. It could be patient transport. Maybe it's the staffing in the admitting department.

"It's really an input, throughput, output situation," she says. "Match output to input, or otherwise there is a bottleneck. So look at the bottleneck and see what you find out."

Another important consideration regarding patient flow is that once the decision has been made to admit an ED patient, that individual is defined as an inpatient, Gilhooley points out. "All assessment and care protocols for inpatients are applicable.

"Say the person [waiting for a bed] is supposed to be admitted to the intensive care unit," she adds. "Do they have access to the same technology if they're on a cart in the hallway? Do they have privacy, access to a call bell? Is the appropriate physician — perhaps a specialist — available to care for that patient?"

JCAHO also expects the hospital to plan for the care of "borders" — patients who are waiting for treatment, for diagnostic results, or to see a specialist, Gilhooley says. "Those kinds of individuals can add to a bottleneck situation."

A subject JCAHO surveyors are likely to address with hospital leadership is whether resources are provided to manage those patients, she says. A point to note would be, "Does leadership take action based on those data?"

While JCAHO's focus has always been to protect the quality and safety of care, the agency is now spending more time on the scene observing, Gilhooley says. "Before 2004, we spent a significant amount of time on policies and procedures, which were the promise of execution. Now we're looking at whether the promise is really implemented."

Post-9/11 emphasis

Since Sept. 11, 2001, emergency management has been particularly important, she adds. Surveyors might, for example, ask any hospital employee such questions as, "What do you do? Who do you report to? What are your responsibilities when the [hospital] implements its emergency management plan? How were you trained?"

A likely question for access staff, Gilhooley says, is "What do you do when the systems are down?"

"Our standards require two drills a year," she notes. "One is a drill when there is an influx of patients. I think [surveyors] might ask, 'Do you use temporary registration procedures? Do you have temporary triage areas and procedures?'"

Surveyors may select a scenario and ask a staff member to pretend that the hospital has just experienced that event, Gilhooley adds. "[The surveyor] may go to all the areas that would be impacted and say, 'Do you know what to do?'"

The whole process involved in the transition, from paper to electronic medical records, is an "up-and-coming" area that JCAHO will focus on, she says. "That transition [period], when some will be using both [kinds of records], is a vulnerable time. We're looking for processes designed to minimize those vulnerabilities."

JCAHO has in the works a task force on health information technology that will address those kinds of issues, Gilhooley adds.

Easing communication challenges

Another important JCAHO focus has to do with eliminating the barriers to patient care sometimes posed by communication issues, she says.

"We've got a lot of standards that apply to language and culture," Gilhooley points out. "We want to ensure that patients' values and beliefs are respected, and [enable] patients' involvement in their own care."

While some of the emphasis is on the provision of adequate interpreter and translation services, she notes, the communication challenges don't stop there.

"What we're finding when we look at language issues, is that people who speak English are also having trouble understanding," Gilhooley says. "It's not just the health care provider imparting information; it's whether the other person understands."

Because so many medication errors occur at discharge, she adds, JCAHO surveyors are now asking questions designed to make sure the discharge conversation has actually been a two-way communication.

"They try to talk to a patient who has already been given discharge instructions if the person is still there," Gilhooley says, "but they can also ask to call and talk with one who has been recently discharged.

"We do have medication reconciliation as a new national patient safety goal," she notes. The idea is to know what medications the patient is coming into the hospital with and which ones they're supposed to be leaving with, Gilhooley adds. "Somebody should be looking at that and managing the whole patient."