Accreditation Field Report

Surveyors focus on informed consent, nails

With its last survey in December 2006, Faith Regional Health Services ended up in conditional status. In the last year and half, Amy Nicolas, RN, BSN, says the hospital did some restructuring. Changes were made at the top. The chief nursing officer was let go; the CEO also was let go and replaced, and a new vice president of medical affairs was hired and put in charge of quality. A lot of that, she says, helped the hospital remove hindrances and refocus on quality.

A Joint Commission prep team was developed, consisting of many clinical directors, a few vice presidents, and Nicolas. The team did monthly tracers in all the inpatient units, the surgical unit, the cath lab, as well as the emergency and radiology departments. Those findings are relayed to the prep team to develop work teams and action plans. Often, the same findings were observed in different units "whether it was blanket warmer temperatures or dating and timing of orders."

She admits the 2006 survey was "bad. We weren't measuring our critical test values. We had a ton of unapproved abbreviations. There was no dating and timing of orders. We didn't have a 24-hour pharmacy at that time and so we had a house supervisor. People were accessing the pharmacy after hours all the time and for nonemergent medication," she says.

"We had an essential medication list, but nobody was paying any attention to it. The leadership wasn't there. We failed our time out when The Joint Commission was here," she says.

The findings didn't compel changes, she says. The leadership staff didn't believe the hospital was at fault. "They thought we just got a group of bad surveyors," she says. At the time of the survey, Nicolas was an inpatient manager, but in February 2008, she took the quality manager position. "I read The Joint Commission's manual. OK, that was painful. But I had to read it because I had to know for myself what we had to do and what we didn't have to do," she says.

"Honestly, the whole organization needed someone who they trusted clinically to push stuff through," she says. And she had good relations on the clinical staff. "But then it really took our new CEO and the vice president of medical affairs who was really aggressive with the medical staff in saying, 'We have to do this. This is our accreditation. This is what makes sure that we get paid.' And that has helped a lot."

She took a few inpatient clinical directors to an accreditation update in fall 2008. "The gal that did that accreditation update was very blunt and very straightforward on, OK if you don't have this, you need to get it. Because even at that time, we really didn't have a concrete critical test value policy. It was kind of a mish-mash of ideas or interpretations; like [rapid response teams], we still really didn't have anything housewide with those. We weren't doing time outs on the floor. Everybody had their own idea of what a time out was. For some people it was just like a time out was done and they didn't even realize there were elements you had to address, and so that helped a lot," she says.

In preparation for its December 2009 survey, the hospital shored up its communication of critical test values, time outs with the help of a new director of inpatient surgery well versed on the topic, and medication storage. "The other thing was the timing and dating of orders, which was disastrous. But with that, our medication reconciliation process really got fine-tuned from the last survey to this one," she says.

They also worked on their informed consent procedures. Nicolas says previously it had fallen into the hands of the nurses, and the dialogue was pretty vague: "You're going to have this done. Here's your consent form. If you have questions, ask me."

Ownership of that was put back into the hands of the physicians with communication that if the patient doesn't understand what he or she is having done, the procedure would be stopped.

With the informed consent policy, the provider asks patients what they believe they're having done. "So if they're having an appendectomy, they may say, 'I'm having my appendix out.' And that's what you're going to put down. And then also the nurse writes that in the medical term," Nicolas says.

And then there's checklists. "Has your physician explained the risks, benefits of this procedure with you? And then they check yes or no. They check if they have any questions or concerns. It's more kind of ensuring that the patient understands what they're having done, that they understand that a physician has explained it to them, not a nurse. And then it also has other questions like it asks them about their DNR status," she says.

Another problem area was pain management. And she had heard The Joint Commission was really monitoring that. "We have a lot of preprinted order sets like a lot of facilities. Each one of our surgeons kind of had his own preprinted order sets, but they all had a different way of using their pain medications. And we really didn't have that well tied into our pain management policy nor pain scale," she says.

"When a nurse has four different choices or three different choices of pain medication, how is she deciding what to give? So we did change our pain policy to reflect that. So there's a little more guidance to the nurse as, 'There are three medications, you can give this. There are seven, you can give that,'" she says.

The other part was education of staff. "[T]he physicians here were kind of used to doing whatever they wanted to do. And some of that, I hate to say that has been taken away from them, but it was like you know you can't just write for whatever you want. [A patient doesn't] need seven different pain medications," she says.

A lot of the physicians she's seen don't like change. And they're not influenced by "evidence-based care." They'll just answer, "Well, I can find other studies that show the opposite." And Nicolas has to say, "'We can't do a control group and another group. We can't test on these patients. We're not going to have a control group and then an intervention group and redo these studies. You can't do that. And this is what we have. And until we have another stick to measure by, this is it.'"

The new VPMA goes to all the physician committee meetings and explains what has to be done. But he stresses that nothing is set in stone and things can be changed if needed.

The survey, she says, was much different than in 2006, more detailed. But she says the surveyors were "consultative and helpful." When it was apparent staff didn't understand, she says the surveyors would ask them if they understood. "And so it was definitely more of a relaxed atmosphere for the staff. So where they didn't feel like they were being tricked or led down a wrong road just so [the surveyors] could say, 'Oh, that's wrong,'" she says.

The surveyors focused quite heavily, she says, on informed consent and storage of medications. They looked at every fluid warmer to make they had the proper expiration dates.

Surveyors found one physician was not reviewing post-op notes because he said he dictates immediately after surgery. "But your dictation doesn't come for another day or so. So he wasn't doing that well. By the end of the week he did," she says.

She says she was surprised that the physician surveyor was "really fixated on finger nails" and whether staff's nails matched what was in the hospital's policy.

"He didn't focus as much on FPPE/OPPE than I thought he would. I know it's been a huge issue. But he just asked us what our process was. He did look at some credentialing files. And wanted to see the photo ID. But he thought the files looked good. But we didn't have a really fantastic process for FPPE or OPPE but he never really dove very hard into it," she says. The surveyor asked how the process was managed and what was done with the information.

She was also surprised that the surveyors did not focus as much on the National Patient Safety Goals. They didn't ask about rapid response teams, falls, or critical values. They didn't ask if standardized kits were used with central line insertions.

"They talked about hand washing of course. They watched for hand washing. But they never watched anybody pass meds to look at are they using the patient identifiers. They talked about the high alert meds. They wanted to see, if you had high alert meds what you were doing with the high alert meds, and we do have a fairly concrete process for that," she says.

The hospital received seven direct impact RFIs while their threshold was eight. One citation was for medical restraints. "We had a time frame in there where we had said that when a physician writes an order for a restraint, not a behavioral restraint but like a line protection — the medical restraint — that he would write in for how long. And then that's what our policy says. But we had a preprinted order form, a carbon that we used, and that wasn't on that carbon form. So the policy really didn't match what the order said and so we got a direct for that since it's a CMS condition," she says.

The hospital was also cited on its last day when the physician surveyor walked into a room with a biohazard sticker, a storage room for the respiratory department. There was a dryer, and he asked to see the maintenance records. There were none, the machine had never been logged in by biomed.

The hospital was praised for its informed consent procedure and for "post-op pain orders, which followed the inpatient post-op pain orders that really tie into the pain scale, which he really liked. It's very clearly written," she says.

"A lot of the stuff that we had the directs on we corrected while they were even still here. A lot of the stuff was very easy. The post-op note, that physician started doing it. The dryer. Biomed was shocked, and they checked it out and put it on the log and changed the HEPA filter. So a lot of things we were doing as they were still here and trying to correct," she says.