accreditation_field_report Field Report

Pain assessment, documentation TJC focus

With its latest survey, beginning May 25, 2010, and ending May 27, Holy Family Memorial had the most surveyors it ever had — seven — and its first life safety survey. Mary M. Schilder, quality management, accreditation/CME coordinator, and privacy specialist, says the surveyors, who visited "every single clinic and department," were "very educational."

"They gave us a lot of different forms that they downloaded for us to be able to drill down into data... They say that the survey agenda is negotiable. It truly is. There were no times listed on it. We could go ahead and work with them on the first day as to when we wanted to do things," she adds.

Prior to the survey, TJC sent an agenda, but if a particular person was unavailable at a certain time, she says, the surveyors were amenable to shifting things around. "If our CEO was busy in the morning, they would move something to the afternoon," she says.

But unlike past surveys, she says the surveyors didn't focus on the National Patient Safety Goals. She says it was truly based on tracer activity. "Everything was done by tracer," she says. "So if there was a National Patient Safety Goal involved in that patient tracer, of course they looked at it, but they didn't go in looking for compliance on the National Patient Safety Goal. They would pick our patient and they would basically work from that point backwards until the entry into our system and looked at every single department and person and order, etc."

With an electronic medical record system for both the inpatient and outpatient side, she says the survey flowed much better. "What we found was really helpful is, we had two experts for the surveyors to go along and be able to pull up things on those records very quickly. And that they really liked. They liked our ambulatory electronic record. They thought that we were light years ahead on that." It also eased other staff to have experts available to locate information on the EMR system, as it is still fairly new. The surveyors also praised how the systems for outpatient and inpatient care "talk to each other on multiple levels."

As part of the survey agenda, Schilder says, The Joint Commission sent a sheet detailing everything that would be needed as part of the survey. "We made sure that was all up to date and ready to go, and this is twice now we've done that, and both teams of surveyors have been very complimentary on that — that they didn't have to keep asking for things. We made sure they were in there and updated. You feel like at least you're starting off on the right foot," she says.

One thing the surveyors not only complimented the system on but asked if they could take with them to offer as an example of a best practice was Holy Memorial's admission assessment for its home care/hospice program. Schilder says as part of the hospital's work with Lean and Six Sigma processes, it found it needed to improve the admission piece. One nurse, she says, took it upon herself to do that, working with other organizations that had a good policies in place. The policy includes "everything from the social assessment to the physical assessment to medications, fall risks, etc. But then we took it one step further and, depending on who this patient was going to need from the community, we contacted them to see what would be helpful on that assessment form or if we needed to send it to them for assistance" she says. The policy addresses two central, and often problematic issues, for hospitals: continuity of care and handoffs.

She says pain assessment was a big focus in the survey, as well as documentation of education including patient education. "Those were two really, really big things. Our inpatient pain assessment is really well done. Of course, we have a lot of outpatient clinics, so now our goal is to get them in that mix to be able to do it as well as the inpatient. It's not that they're assessing pain. Oftentimes it's the documentation of it. And then what happens after you document it," she says.

She says the hospital is using the Lean process in developing its own pain assessment scale. "It really has to be a template," she says, not simply asking: What is your pain level and are you taking something for that pain? She says it should include:

  • What level was your pain before you took your meds?
  • Are you taking your meds?
  • When was the last time you took your meds?
  • Is it helping you?

"And then that needs to close the loop by going back to the physician with the report. I believe we're doing that. It's the documentation part of it [that we're working on]. We're going to have to build something into our ambulatory electronic record," she says.

On H&P timing and dating, an oft-cited standard for hospitals, she says Holy Memorial has improved by automating and requiring those fields be filled in the EMR.

Post-survey, she says, the hospital is reviewing some of its environment-of-care plans. "They wanted just a little bit more on the data things in there. We are looking at our emergency management plan. They really liked our emergency management plan, but one of the things that was missing or they thought wasn't addressed enough was what resources do we have to get our hospital and network back to normal after an event. Do we have the resources? Do we have the people? How are we going to let our people who've worked through all this get rest? Are there people to replace them?"

Another area, this one in life safety, the hospital is going to be looking at is its durable medical equipment service. Surveyors wanted that service to have its own disaster drill and also found some things that were outdated, such as sutures. "They probably haven't done sutures in that clinic since they were outdated. But because of that, we're going to have a policy in place. It's going to talk about a stop-gap so if there is an outdate that it's checked before use on the patient just so we have it as part of our standard work. So there's a stop-gap there."

As part of the hospital's falls program, the surveyors asked if it could further categorize risks. So, for example, she says, in the mother-child unit, surveyors "talked about changing that falls assessment from low risk until [the mother] can get up and ambulate because maybe she's still on some pain medications to change that up into a higher risk. And that was being done but again not documented. So we're going to have to put some kind of a flag on that in our system."

Her suggestion to other facilities preparing for their survey: Give surveyors their space. "Remember to be respectful of them and get out of their space and let them prepare for the day and just wait. That's all you can do."

(For more information contact: Mary M. Schilder. E-mail: