Accreditation Field Report

Surveyors look at IC 'everywhere'

Documentation, medications also key

It was the first Joint Commission survey for Elizabeth Donnenwirth, RN, accreditation/sharps safety specialist at Winchester Hospital in Winchester, MA. But she says there weren't many surprises.

The week-long survey for the hospital, which has 189 licensed beds, was performed by two nurses, a physician, and a life safety specialist. Surveyors looked at the usual suspects: infection control, documentation, medication, and competencies, she says. Coming in December 2010, right under the wire for the changes coming in the life safety/environment of care surveys, she says, surveyors also focused on EOC issues such as clutter.

Unlike the Centers for Medicare & Medicaid Services' surveyors, who "start from the patient and work up," she says, The Joint Commission surveyors asked some patients questions, "but they didn't really focus on patient communication, not from the perspective of speaking to patients. They were very focused on communication in general."

She reports no real surprises, noting that the surveyors touched on every standard in the manual. She says she was surprised, however, at "the extent that they focused on infection control because we have extremely low infection rates."

As the time rolls on post-survey, she's hearing more and more from staff in particular areas. "Being the accreditation specialist, I was neither escort nor scribe. I was involved in one area with a question-and-answer session with the physician surveyors when they were already in the ED talking about something else, and I came to answer a question."

She says the hospital has an ambulatory care unit on site, but it's very small; the hospital itself is 100 years old. So there are a lot of offices off-site. Many of the endoscopy nurses visit the off-site clinic, going back and forth from the on-site to the off-site office. The surveyors watched the processes there, specifically surrounding cleaning the scopes for colonoscopies. Donnenwirth wasn't surprised that they went to the off-site clinic, as surveyors usually go to at least 50% of your off-site clinics, she says. The surveyor looked at the drying racks for the scopes and looked at the floor and said, "Oh good, no brown spots."

Staff "looked at him, and they were appalled that he would even think he would see that, and he said, 'Oh, you'd be surprised.'" Surveyors do seem to compare hospitals and have their own pet peeves, she says. "One of my personal things is hand hygiene and cleaning scopes and things like that. I also do sharps safety, so I'm really fussy about that kind of stuff. And these surveyors have their own. One of the surveyors, the home care surveyor, was also a home care nurse so she did the home care survey... That's where she felt comfortable, and they had a good review even though she was tough with the questions. But she also came into the hospital and did a lot of infection control stuff and spoke to patients in isolation."

Overall, she says, surveyors were surprised by the size of the hospital and how well they were doing "because apparently a lot of smaller hospitals have more difficulty because you have one person wearing a lot of hats."

They emphasized documentation and policies, she says, and asked to see many files. They asked for an OR block time for a particular surgeon and spoke with her about how she schedules. Surveyors looked at physical and occupational therapy for the rehab perspective. "They asked, of course, in all the sessions, to see a lot of information straight out of the data," she says.

As for infection control, she says, "everywhere they went, they looked at the infection control aspect of it." The surveyors asked about the solution that's put into the whirlpool bath to keep it free of bacteria and the processes involved. They asked a housekeeper how she prepares that solution and how she could ensure that it's the same every time. Donnewirth says that process has been standardized so that all that is needed is for a staff member to push a button and the solution is mixed perfectly. "[I]t's pre-measured in this machine. And the company that supplies us with this comes every month to make sure that it's measuring exactly the right amount... In some hospitals, they have to measure it. So how do you know it's perfect?"

Surveyors, she says, looked at all the containers for labeling. Even the solution used to clean the tray and table area after scopes are cleaned has to be labeled, she says, because it's a "secondary container."

Overall, the hospital received kudos for staff working well together. Surveyors "could tell it wasn't put on for survey week. That [staff] truly did work well together. The communication, hand-offs, things like that, they were very impressed with." Surveyors also complimented nursing documentation and nursing patient care plans. "One of the things we were told they would focus on, and they did, was care plans. You look at the patient assessment and then [ask], 'Were those things that were identified put into the care plan?'" For example, if a patient is identified for falls risk, how is that implemented and checked on?

"So they drilled down to, 'OK, you identified these four things when the patient was admitted in the first 24-hour admission assessment. And now, how do you know that you're addressing them? And how do you know that it's resolved? And what happens when, OK that goal is done and you have a new goal? How do you identify a new goal?'... They were very impressed with that," she says.

She says, of course, surveyors looked at legibility involving histories and physicals. "We did find some entries where timing was missing, so we did get hit on that," she says. Staff are "pretty good" with dating, she adds, but have not been so consistent with timing, specifically in certain areas. The hospital is only half-electronic. So timing may not be as good in some of the off-site clinics not yet on an electronic system but better in the hospital because of CPOE. The hospital also got cited for hospital clutter, certainly no uncommon finding.

"Some of the nursing units are larger than others in terms of room size," she says. Surveyors found in some hallways a couple of IV poles, a computer on wheels chart, and linen carts. Moving forward, she says, linen carts are going to be put inside patient rooms. Nursing and housekeeping, she says, are actually happy about the change, which will make their jobs easier.

She suggests asking any and all questions you may have for the surveyors while they're there. The more clarification you can get, the better, she says.