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Surveyors educative, more collaborative
Demonstrating that you're prepared is important when Joint Commission surveyors knock on your door, says Susan Bukunt, RN, MPA, CPHQ, senior director of clinical quality and patient safety at El Camino Hospital with two campuses in Los Gatos and Mountain View, CA. "Being able to give them what they're asking for shows them that you're ready and you take this seriously," she says.
Prior to El Camino's most recent survey, Bukunt had readied all the documents on The Joint Commission's survey prep guide in binders. "We had our team on alert so that when we called, we mobilized everybody, and by the time of the opening conference I had all of my escorts ready. I had every binder that they could ask for in terms of committee minutes. Everything that was on that list we had into that room by 8:30 in the morning. And so that showed them that we were prepared and we were organized."
She also had a PowerPoint presentation ready for the opening meeting with the surveyors, who came seven months prior to their tentative "due date." "I've heard some surveyors do not let you [use presentations]. We decided to have it ready for those things and then just keep our data updated so that even if they said, 'We don't want a PowerPoint, we just want you to talk,' people would have discussion points in front of them." So if a surveyor said, tell me what you've been working on that you've had success or not so much success with, "we had those examples there for people in the room to sort of rattle their brains to think about. And that made people feel more confident."
In preparation for the survey, Bukunt says there are 23 "surveyors" at the Mountain View campus and about 10 at the Los Gatos campus. Those are managers or directors within the organization who have been trained to do monthly surveys. They are outfitted with a checklist of about 75 items, and then the information is put on the hospital's dashboard. "So on the dashboard, if you miss one item it's red for the whole hospital. Everyone has to be perfect for it to be green. We post it on our internal web site and all the managers, they can drill down to their own unit level. They can drill down to a service line level or they can look at the entire hospital," she says.
When she surveys a unit, she takes the checklist with her and interviews staff while walking around the unit. She pulls a patient's record, a physician record, and a competency file. "And then before I leave the unit, and it usually takes about two hours to do a survey, we make a copy of it and I do a debrief with the manager of that unit and tell them what they missed and why they missed it," she says.
The surveyors arrived in March. Bukunt says that in California, the Institute for Medical Quality (IMQ) accompanies The Joint Commission on its survey and provides the physician surveyor. She says the surveyors were more collaborative, thorough, and educative "a big difference in their approach from our survey three years ago."
"They put the staff at ease more so than I've seen them do before," she says.
They also were willing to look at clarification. "So if they had a question about something, it was 'Show me,' and I could produce a document. I could produce an audit. They were willing to look at that and take that into consideration."
Surveyors focused on patient safety, the National Patient Safety Goals, and especially life safety compliance. The system received no direct findings, only five indirect ones.
"I think one of the things that the surveyors were very complimentary of was our quality program and our use of data. And they liked the fact that they could trace the data through committee minutes and see closure where things had been looked at, talked about, and we said, 'This went up the chain of command or it went through the process,' they were able to trace that. One of the things they really liked was when we showed them some data. The surveyor could immediately see where we had a problem and asked us about that and then we were able to show him that that was one of our performance improvement projects. So he was impressed that our data were easy to read and understand," she says.
The hospitals use dashboards and a quality steering committee comprising board members, chiefs of staff, hospital administration, and the quality team. "They set the goals for the organization and what we will look at. And then they review the dashboard to make sure that we're on track with what we're trying to do," she says.
The report includes all of the quality measures the system is looking at. Bukunt says the national benchmark is included but is not the measure they use. The measure is getting to zero for things such as pressure ulcers and falls and getting to 100% for measures such as patients getting to the cath lab under 90 minutes.
She says surveyors talked about the Centers for Medicare & Medicaid Services (CMS) and the conditions of participation more than in the past, and if they cited a standard they would also site the corresponding CoP.
Surveyors asked to see the grievance policy and any grievances filed within the year. The hospital has scorecards in which data on physicians are fed. Although she says the process is still in progress, she says the surveyors were pleased.
One of the indirect findings related to timing, dating, and signing of H&Ps. The surveyors observed three instances in which physicians did not time entries in the medical record. "And so we did a clarification where 30 days prior to the survey, we looked at 70 records and did an audit of those records, and we found that we were 98% compliant with everything in the record being dated, timed, and signed. So we sent that back to The Joint Commission as a clarification to say, 'We think that we were in alignment with that.' And they may come back and say no. Or they can say, 'OK, we accept that and we'll take that finding away,'" she says.
She says the hospitals use an EMR system in which CPOE and nursing documentation are recorded for some units. "H&Ps and consultations are dictated and go directly into our electronic record so they get electronically dated and timed when they're entered. And then the physician signature. Where we have the most problem is physician progress notes because those are still written by hand. So we've added a time column to the progress note, which was never there before. So we have a date and time column on the progress note, and that has really helped improve compliance for our physicians."
The hospital does audits of records, and when a lapse is found, the chief medical officer sends a note to the physician with the problem. It also goes on that physician's credentialing file and ultimately on the OPPE. If there is one miss, a physician gets the letter. "We're still trying to establish the threshold for how many times you can get a letter before it becomes a problem. So it's a work in progress for us," she says.
Other indirect findings were in the area of life safety, and all were corrected on site. There were issues around fire doors that didn't close completely and crash cart placement. The carts needed either to be locked or out of sight. "And they did not consider the breakaway red locks as being locked," she says.
Because they had just moved into a new hospital in November, almost all patients rooms are private and the units are bigger so they're struggling with having the carts closer to patients' room rather than to the nursing station.
"I have to say the team we had was very open and willing to talk about things and giving suggestions 'Maybe you could do this' or giving us a reference, 'This is what I'm talking about, this is where you can go look for it.' It was so much better than we've had in the past," she says.