Unannounced surveys: What JCAHO asks ED nurses

Surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) were in the ED many times during a three-day survey at Franciscan Skemp Healthcare in Lacrosse, WI, reports Barbara Sue McBride, RN, patient care director of the ED. The ED was one of the first to be surveyed under the Joint Commission's new unannounced survey process.

"There is no such thing as having the department spic and span for an unannounced visit," says McBride, who points out that surveyors may enter the ED several times during the course of an announced survey. "They did not want to talk to management, so I wasn't even aware they were in the department until after the visit."

Here are some questions asked of ED nurses:

• What is your process for obtaining a list of the patient's current medications?

During one patient tracer, surveyors compared an inpatient chart with the ED record and initially thought a medication list was incomplete. "They determined that these were new medications since admission, but then the surveyor asked the nurse to describe how we go about obtaining medication history," says McBride.

The nurse explained that the patient is asked for a medication list or pill bottles, and this information is combined with the hospital record to check for discrepancies. "If none of this is available, we contact the pharmacy where the patient obtains medications," says McBride. "We also have clinic visit notes online, so these can be checked."

• If a patient came in and didn't speak English, how would you get a list of current medications?

ED nurses told surveyors that the same process for medication reconciliation would be used, but an interpreter service would be utilized with information verified by the patient, says McBride.

• What is the process for patient assessment?

"Our ED record is rather unique," says McBride. Besides the usual triage information, a general secondary assessment is obtained for every patient including fall risk, mental status, general appearance, activity, skin parameters, abuse, and nutrition screens, she explains. "Once placed in a room, a further focused secondary assessment is completed based on the presenting complaint," she says. "For instance, if they come in with abdominal pain, the pain assessment as well as the gastrointestinal/genitourinary/reproductive assessment portion is completed."

• What have you done in the last few months to increase patient satisfaction?

ED nurses explained that staffing patterns were evaluated, and additional nurses had been added for 11 a.m. to 3 p.m. weekdays and 11 a.m. to 11 p.m. weekends. "The nurse told the surveyors that during these busier times, patients get more prompt attention," says McBride.

• How do you ensure that lab tubes are not outdated?

LuAnne Kratt, ED nurse and sexual assault nurse examiner (SANE) coordinator, showed the surveyor the expiration date on the tubes and also told her that a patient care technician is responsible for keeping supplies in date.

• How do you know narcotics were not diverted for other use?

When Kratt told the surveyor that the drugs were replaced from the automated medication dispenser to the paramedics, he then asked how she knew that the medications actually were given. "I told him that I didn't, but that we were all professionals and had to believe them," recalls Kratt. "It's the same as trusting my peers to give narcotics when caring for patients on the unit."

The surveyor accepted this response, although he may have been looking for a fail-safe program to ensure that narcotics have not been diverted in the field, she says.

"We discussed how to assess the patient's pain level and the relief he or she is receiving," says Kratt. "This is often difficult in a trauma situation or with an altered level of consciousness."

• Why do you stock three different strengths of epinephrine?

The surveyor was concerned that these different strengths could result in medication errors with incorrect dosages given, says Kratt. Kratt informed her of their Code Blue committee that meets monthly to develop policies and procedures and address concerns with the code carts. "I told her I would share her concern with our ED's representative to that committee," she says.

• How do you provide support for domestic abuse victims?

Surveyors were impressed with the ED's domestic abuse program, which includes on-call advocates and free follow-up counseling by master's-prepared social workers. "We are able to be very supportive to victims of abuse," says McBride.


For more information on accreditation surveys, contact:

  • LuAnne Kratt, SANE Coordinator, Emergency Department, Franciscan Skemp Healthcare, 700 West Ave. S., Lacrosse, WI 54601. Telephone: (608) 785-0940, ext. 4919. E-mail: kratt.luanne@mayo.edu.
  • Barbara Sue McBride, RN, Patient Care Director, Emergency and Urgent Care Departments, Franciscan Skemp Healthcare, 700 West Ave S., Lacrosse, WI 54601. Telephone: (608) 785-0940. E-mail: mcbride.barbara@Mayo.edu.