Accreditation Field Report

Survey is rigorous, but staff get morale boost

JCAHO likes very visual’ data

During a recent unannounced Joint Commission survey at Presbyterian Healthcare in Charlotte, NC, staff underwent a "rigorous, in-depth" process, says Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review. "By that I mean that each of the surveyors were experts in their field and knew their standards," she says. "But the staff were left feeling good. Basically they caught us doing our own thing, and they liked what they saw."

During previous JCAHO surveys, there was a feeling that surveyors were on the lookout for mistakes made by staff, as opposed to observing what they did right, says Swain. "There was a lot of chatter about failing. This time we walked through what we do everyday and got credit for it."

Surveyors wanted direct responses from staff as opposed to staring at story boards or charts, says Swain. "Story boards are passé — people can still do them for internal purposes, but surveyors don’t like them because they are flat. Surveyors want to hear staff talking about the care they give," she says. At the end of the survey, one of the surveyors gave a compliment that "the managers were there, but the staff talked." "They said it really shows us you have confidence in your staff, which tells us a lot about the organization," says Swain.

Surveyors wanted to see graphics to illustrate performance improvement processes. "You can’t just have the summary data; you’ve got to have the data that shows the drilldown and deliberation process," she says. "You’ve got to defend your quality processes for improvement."

Here is specific feedback given by surveyors:

Tracking of medication errors and occurrence reports.

These data need to be "very visual" to show that improvements were made and that your gains were sustained over a period of time, says Swain.

"There is a system tracer on medication management where they expect to see improvement for monitoring medication errors, so that needs to be well laid out with graphics analysis," she says. "You need to show, Have you fixed this?’ and Did it stay fixed?’ You can’t talk about it otherwise."

Surveyors will want to know what your analysis showed, and whether you have drilled down, says Swain. "If you haven’t done the PI process well and have that documented, you’re talking off the top of your head. With medication management, they are extremely well versed," she says. "They looked at all of our data, and we had about a day to pull everything together."

The organization uses an electronic medication administration checker (MAC) system, which has the ability to track error reports, adds Swain. "The surveyors wanted to know what trends and patterns were identified. We had identified that overriding of the system in several areas was an opportunity," she says.

Transport of crash carts.

While tracing a patient who was resuscitated, surveyors went to pharmacy and then to materials management to check whether supplies and medications were locked while in transit — in effect, tracing the path of the code cart. "The surveyors noted that the people transporting the crash carts didn’t have special training in medication security," she says. This led to a simple change in policy: Staff no longer take open drug trays to pharmacy. Instead, these are locked before they go into storage. "The staff were trained to a new process that secures a used cart with a different-colored lock," she adds.

After-hours entrance to the pharmacy.

The after-hours access log was requested, as well as training of non-pharmacy personnel who entered the pharmacy and what drugs were being taken out. Surveyors discussed their expectation that there be minimal access and were happy with the provisions made to stock pharmacy inventory in other high-use sites, such as the emergency department and intensive care unit.

Operative notes for procedures.

Surveyors noted that a pediatric patient had an operative procedure, but no operative note was dictated that day. "The standard says you need the note dictated within 24 hours," says Swain.

Protection of stored equipment.

"We had many medication infusion pumps kept in a storage area that was near construction, and they wanted to see that we protected them from dust and dirt, because you will be taking that into the patient’s room," she says.

Flash sterilization in the operating room.

"They really like to see very little flash sterilizing," she says. "Our organization will review the practice, to validate what our frequency really is."

Inconsistencies in documentation.

When an orthopedic patient was being traced, surveyors noted the patient was at high risk for falls — something that wasn’t noted on the flow sheet. "She had a cast on postoperatively, which made her at high risk for falls. They were looking for that to be reassessed and updated," she says.

Vendor documentation.

For vendors who come to departments such as operating rooms (ORs) and information technology, JCAHO wanted to see a vendor file with orientation to the area and confidentiality agreement signed.

Range orders.

"The issue is whether a nurse is practicing medication without a license," she says. If a nurse gets a range order for 2-10 mg of morphine sulfate to be given intravenously to control a patient’s pain, for example, surveyors want to know how the nurse determines what dose to give. "Our policy says that they give a drug based on assessment, and they start on the lowest level on the range." When surveyors interviewed a staff member who had a problem describing this process, the command center sent out an all-points bulletin so all staff could review the practice and articulate clearly. "We sent out an e-mail to everybody with the policy so could do a quick review. Thus, surveyors did not find this problem again."

Policy for temperature and humidity ranges in the OR.

Surveyors asked staff what to do when these fall out of range and found that the individuals being interviewed were unclear about the process. "Although we had a policy for this and it was addressed in our training process, staff wasn’t comfortable explaining it to the surveyor," says Swain. Quick action was taken so this problem wouldn’t occur again during the survey, she says. "We put it on our command center update information list that went out to all staff. In addition, that evening, during a manager debriefing, we decided to "wallpaper" the OR, and we put a sign in every OR that listed temperature range and what to do if it was outside that range, so that every single staffer knew that policy."