Accreditation Field Report: TJC survey focuses on infection, hazards, OR
TJC survey focuses on infection, hazards, OR
The director of quality and risk management at Mendocino Coast Hospital in Fort Bragg, CA, Susan Bivins, RN, wasn't sure The Joint Commission was going to show up for the hospital's survey. When the hospital went to a critical access hospital status in 2006, TJC had come in for a survey and told them they would revisit in 12 months to evaluate their status as a critical access hospital. So the hospital waited. But it wasn't until two and half years later that The Joint Commission surveyors showed up on Nov. 16, on schedule for the facility's regular triennial survey, due to expire Nov. 30.
Bivins says one of the surveyors remarked that it was great to see a critical access hospital keep its Joint Commission accreditation, "because [the surveyor said they] are seeing a trend of smaller hospitals dropping Joint Commission because it is expensive. It's costly to maintain and keep up the standards," she adds. But Mendocino Coast Hospital's CEO was determined to maintain accreditation, she says. He had come to Mendocino from a hospital that had never been Joint Commission accredited, and Bivins says he saw a big difference in the standard of care.
Mendocino had three surveyors. An engineer came the first day to review the life safety standards. Bivins explains that the facility is 38 years old and says there's a lot of repair work to be done but credits the plant maintenance department for keeping things up. She says the surveyor also was complimentary but cited the hospital for two things. 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 eight feet and it wasn't," Bivins says.
She notes the difficulty of trying to find places to store things and questions 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.
The other area the surveyor found out of compliance was in emergency preparedness. Bivins says "he felt that we did not use our community resources enough when we did our hazard vulnerability analysis." She says the hospital is in an isolated community, within a range of mountains. "So we can easily get cut off with power or road conditions, and we did not have communication. Although we've had drills with our city and county services people, when we did our HVA, we didn't have documentation of what they feel the vulnerabilities were for the area," Bivins says. An easy fix, she adds. She plans on inviting them to the next planning committee meeting and to document their responses.
Next, came the survey of Mendocino's home health agency. The surveyor spent two days with staff and attended physical therapy visits, home visits, and visits with home health aides. In one case, the hospital was cited for an infection control violation because the nurse put her bag on the floor without a barrier.
The home health agency and the hospital also got cited because in its infection control risk assessment, it "had not gotten the information from the county as to what's involved in the county area for risk identification with infection control," she says.
"We need to look further than our own hospital organization when we're looking at these risk assessments and vulnerability analysis," Bivins says. "And that's the first time that's ever come up. So I think this must be a new focus for them."
She already has contacted the county and gotten the information that was necessary — data such as epidemiologic information about the county. Bivins says the hospital had been focusing on H1N1, like so many other facilities, "but in our risk assessment, [the surveyor] wanted us to look at other areas that relate to the county."
Mendocino also has a rural health clinic, which is in the process of moving to electronic records. In pulling a couple of paper charts, the surveyor found old medication lists that had "do not use" abbreviations and cited the hospital. Once the clinic has moved to electronic records, planned for Jan. 8 when the hospital's action plan is due to be completed, those abbreviations will not be allowed. The clinic was acquired a couple of years ago, never having been accredited, and Bivins says despite working with them on it, the doctors have been resistant to eliminating unapproved abbreviations.
What surprised her the most about the survey process was the scrutiny on and time spent in the operating room in the surgery area vs. the nurses' floor. "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. She spent a lot of time in our GI lab and watched an ophthalmology survey and looked for time outs and site verification.
"Unfortunately, we did get dinged because our physicians had been really resistant to this year's change when the physicians had to mark the site. They were refusing to mark the site and so we got written up for that. Now it's made believers out of them and we will be changing that," she says.
She says now she has more clout when she goes to the medical staff to say this is something we have to do. "And fortunately, our chief of staff was there, heard the citation, heard the discussion, understands the problems, and will make it happen."
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 or fever or other adverse events.
Now Bivins says the outpatient surgery pre-op form will include a box that signifies the patient has been educated; then electronically the box will be on the post-op checklist (the outpatient department is still using paper, and the inpatient department is using electronic records).
Another citation was a 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. Well, it has 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. The surveyor said it had to be before 24 months. "So we missed the whole group of our department of medicine," Bivins says. "A whole big group of them missed the reappointment date by three days." But it's an easy fix, she says. "We'll just move everything up a month."
Surveyors were "very 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 that that's been a problem area for many hospitals.
Another compliment went to Mendocino's medication reconciliation process, another tough spot for most hospitals. "We have a really good program," Bivins says. "Our pharmacists just took this on and worked with the docs and worked with our local pharmacies... We had decided we weren't backing off [on med rec] because we had a good process." Bivins credits the success to the pharmacy department, which championed the program. The surveyor took with her copies of the policy.
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 says.
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 on the charge.
Surveyors also complimented the hospital's use of healing techniques such as guided imagery CDs for surgeries. Its anticoagulation clinic also got a good mark.
What was she surprised about the survey? "Really looking at our operating room really surprised me because it's always an area that's usually so well run and non-problematic that they usually do a pass through of the outpatient department and on to the acute floor. 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.'"
Bivins says the surveyor did not spend much time in the emergency department looking at how things are processed there or how patients are triaged. She estimates the surveyor spent about 20 minutes there, 40 minutes in the med/surg unit, and about an hour in the intensive care unit.
The surveyor didn't visit the radiology or cardiopulmonary units or the laboratory, which had been surveyed in May. Bivins said at that point surveyors had found a problem with blood transfusion documentation so she was surprised the surveyor did not check on that.
The surveyor did spend a lot of time on infection control and hand hygiene surveying, Bivins says. She adds that 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. So 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.
[For more information, contact: Susan Bivins, e-mail: [email protected].]The director of quality and risk management at Mendocino Coast Hospital in Fort Bragg, CA, Susan Bivins, RN, wasn't sure The Joint Commission was going to show up for the hospital's survey.
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