Accreditation Field Report

JCAHO wants hospital leaders involved in quality

Staffing also a key area of focus

Information management, communication, quality improvement, and staffing. These were four key areas of focus during a recent unannounced JCAHO survey at Harbor Hospital in Baltimore. "Surveyors noted our hospital's readiness and longevity and experience of staff. Overall, the surveyors were fair and made the staff comfortable during the tracers," says Nilda L. Ledesma, RN, director of quality case management.

Here are some specific items surveyors wanted to see:

  • Receipt of critical test results. "What they are looking for is the timeliness of reporting to the responsible licensed caregiver," says Ledesma.
  • Documentation of timeout for bedside invasive procedures, such as lumbar punctures or insertion of a central venous catheter.
  • Medication reconciliation across the continuum of care.
  • A complete pre-anesthesia assessment for patients undergoing moderate sedation in interventional radiology.
  • Discharge instructions that were understandable by the average layperson. In some cases, residents and attending physicians were writing medical abbreviations such as "PO" instead of "by mouth," says Ledesma.

The physician surveyor conducted the environment of care (EOC) tracer and building inspections, and discussed the EOC plan with a risk manager, the plant operations manager, a clinical engineer, and a security officer.

To assess emergency preparedness of the staff, the surveyor interviewed nonclinical staff, such as asking an employee in laundry what she would do in the event of a fire.

Surveyors liked that hospital leaders were involved in the organization's strategic and quality initiatives, including the rapid response team, fall prevention, stroke, heart failure, heart attack, pneumonia, and sepsis efforts.

In preparation for the unannounced survey, the hospital developed a task force to review the standards for continuous compliance on a weekly basis, developed a code to alert the chain of command when mock unannounced surveys occur, and conducted unannounced tracers. "During mock tracers, managers gave staff either a certificate of compliance or an RFI certificate. Staff counseling is given by managers as appropriate, depending on the seriousness of the error," says Ledesma.

[For more information, contact:

Nilda L. Ledesma, RN, Director, Quality Case Management, Harbor Hospital, 3001 S. Hanover Street, Baltimore, MD 21225. Telephone: (410) 350-3702. Fax: (410) 350-2053. E-mail:]