Joint Commission focuses on the operating room

When Mendocino Coast Hospital in Fort Bragg, CA, recently underwent its accreditation survey by The Joint Commission, the biggest surprise was the scrutiny on and large amount of time spent in the operating room in the surgery area vs. the nurses' floor, says Susan Bivins, RN, the director of quality and risk management.

"I really thought it would be the other way around," she says. "I think [the surveyor used to be] an OR nurse and felt very comfortable there." The nurse spent a significant amount of time in the GI lab and watched an ophthalmology surgery. She looked for timeouts and site verification, Bivins recalls.

"Looking at our operating room really surprised me, because it's always an area that's usually so well run and nonproblematic that they usually do a pass-through of the outpatient department and on to the acute floor," she says. "Although [the surveyor] didn't find many things wrong in the area, she did spend a lot of time there. That was quite a surprise and I kept thinking, 'She's shorting all the other departments.'"

The OR did not come out of the process unscathed. The physicians had been resisting marking the surgical site, and the hospital was cited, Bivins says. "And fortunately, our chief of staff was there, heard the citation, heard the discussion, understands the problems, and will make it happen," she says. "Now it's made believers out of them, and we will be changing that." Bivins expects to have more clout when she goes to the medical staff in the future to say a change is required.

The surveyor also reviewed the post-op notes on patients returning to the nurses' floor from outpatient surgery. She cited the facility for "not documenting the fact that we educated the patient on what to expect," including informing them of such things as the site would be marked, two forms of identification would be checked, and that the patient should notify the nurse if he or she experienced pain, fever, or other adverse events, Bivins says.

Now, the outpatient surgery pre-op form will include a box that signifies the patient has been educated. For inpatients, the box will be on the post-op checklist, she says.

Additionally, an engineer came the first day to review the life safety standards. The surveyor was complimentary but the hospital was cited twice, Bivins says. One was for clutter in the hallways.

"We had a gurney in the hallway, and we had the COWs [computers on wheels] in the hallway. [The surveyor] went by with his 8-foot tape measure to make sure the egress was 8 feet, and it wasn't," Bivins says. She points to the difficulty of trying to find places to store things and questions about where to put the carts when the nurse is with a patient and leaves it at the door. The hospital now has designated storage areas on both ends of the hallway where the carts will be stored.


For more information about surveys by The Joint Commission, contact:

  • Susan Bivins, RN, Director of Quality and Risk Management, Mendocino Coast Hospital in Fort Bragg, CA. E-mail:

Surveyor examines recredentialing process

When Mendocino Coast Hospital in Fort Bragg, CA, recently underwent its accreditation survey by The Joint Commission, there was a hard lesson learned.

The medical staff coordinator who works on the recredentialing process "was under the opinion from previous surveys that as long as the final reappointment approval fell within the month of the two years previous, it was OK, which meant that if the board meeting met at the end of the month for the final approval, then that would be approved," says Susan Bivins, RN, director of quality and risk management at Mendocino Coast.

During the survey, the coordinator learned that the recredentialing had to be before 24 months exactly. "The surveyor actually called back to The Joint Commission to clarify that" when the medical staff coordinator said she'd been told it had to be within the month of the previous date, Bivins says. The surveyor said it had to be before 24 months.

"So, we missed the whole group of our department of medicine; a whole big group of them missed the reappointment date by three days," Bivins says. "But it's an easy fix, she says. "We'll just move everything up a month," she says.

Where they received compliments

Surveyors were complimentary of the hospital's work on the ongoing professional practice evaluation (OPPE) and the focused professional practice evaluation (FPPE). Bivins says the surveyor commented those areas have been a problem for many providers.

Another compliment went to Mendocino's medication reconciliation process, another tough spot for most providers. "We have a really good program," Bivins says. Bivins credits the success to the pharmacy department, which championed the program. The surveyor took with her copies of the medication reconciliation form.

Bivins says they have strong policies in place for monitoring and labeling look-alike, sound-alike, high-alert drugs, as well as disposing of narcotics such as fentanyl patches, which the surveyor commented was one of the strongest she'd seen. "We log the drug in, and it goes to a special receptacle, so it's checked there, and there's no concern of someone getting a hold of it and siphoning out the drugs or disposing of them in the regular trash," Bivins explains.

The surveyor also was impressed with the sample medication storage in the health clinic. Bivins says when the hospital took the clinic over, there were drug samples everywhere. And it was "a hard sell" to change that, but again the pharmacy department took charge.

Surveyors also complimented the hospital's use of healing techniques such as guided imagery CDs for surgeries. Its anticoagulation clinic also received a good mark.

The surveyor did spend a lot of time on infection control and hand hygiene surveying, Bivins says. The hospital had started surveying hand hygiene observance in July, but had not compiled the results yet or had enough data to aggregate and report on, she says. The surveyor cited them for "not having gone to the next level of taking the results and really looking at what we're doing. So, we just need to tighten that up, but we had a good process in place," Bivins says.