Accreditation Field Report

Quality control is major theme during survey

Open chart review significant survey component

If Joint Commission on Accreditation of Healthcare Organizations surveyors noted a potential problem area in one department at Hurley Medical Center in Flint, MI, they didn’t stop there. Instead, they zealously looked for evidence of the same problem throughout the facility.

"It was a moving target," says Michael Boucree, MD, the facility’s vice president for medical affairs. "It seemed as if they would look for anything out of whack and then focus on that issue on each subsequent unit to see if there was a pattern, or if it was a unique occurrence."

If a problem was seen twice, it became a recurring theme on a daily basis, he adds. "With regard to one issue regarding multidose vial labeling and test solutions used on the units, the surveyor commented at the Wednesday morning conference, You apparently got the message out after Monday, because I didn’t find this issue again.’"

Here are key aspects of the July 2003 survey:

There was an overall focus on keeping patients and workers safe.

Surveyors continually addressed quality control issues in addition to the National Patient Safety Goals, Boucree says. "They looked at how we assure employee and patient safety and then tested our responses by comparing what we say in documents to what we actually do," he says.

For example, surveyors checked that rooms were adequately ventilated where cleaning solutions were used and that the solution was being used according to manufacturer’s guidelines. On a pediatric unit, surveyors wanted to know how the organization got information about recalls for unsafe devices and how the particular unit would be notified of these changes.

For each of these areas, the surveyor checked the unit’s policies against the actual practice observed by the surveyor. "If what the surveyor saw did not match up to what we said, we tried to clarify the issue," says Boucree. The surveyor then would "test" this on another unit or area to be sure that the facility was not misrepresenting actual practice, he says.

The new tracer methodology was evident, with surveyors following a patient who went into the OR to see that a complete history and physical was done, then looking at postoperative orders, and finally, going up to that unit to check that the orders actually were being carried out in a timely manner.

Surveyors were asked for input on the spot.

If problem areas were identified, quality leaders frequently asked the surveyor to document their point of reference so they could read the full context to ensure understanding of what they were being told, Boucree says. When possible, problems were fixed on the spot or by the end of the day, and a memo of correction was immediately provided to the surveyor, he reports.

Open chart review was a significant component of the survey.

One of the first things surveyors did upon arrival to a unit was to pick a chart and visit with that patient, or to visit a patient and then review that chart, Boucree says. "The surveyors might say that they were coming back to the particular unit or area to see something specific, which obviously gave us a heads-up," he says. "If any issues were identified on one unit, we quickly spot-checked other units for this same vulnerability."

The surveyors commented that the facility had done a good job of implementing the National Patient Safety Goals, and it was one of the few organizations that didn’t get the Special Type 1 Recommendations. Boucree attributes this to creating a task force to implement policies and procedures to comply with the goals, and setting up monitoring activities to demonstrate compliance.

"The staff’s ability to discuss the goals also was evident," he says. "We were a bit shy on the data relative to this, but there was ready evidence of our efforts of compliance."

The facility’s plan of care was scrutinized.

Boucree explains that there had been significant staff turnover due to retirements, resignations, and layoffs in the previous year. In addition, the facility posted a $24 million dollar loss in the prior fiscal year. "Thus, the year prior to our survey was riddled with corrective action plans and intense staffing and budget monitoring," he says.

As a result, there were inadvertent inaccuracies in the plan of care, which caused surveyors concern. "The department in question, which was a nonclinical area, was besieged by absenteeism," Boucree says. "There were many adjustments in this department from a staffing, managerial, and process improvement perspective."

Since the survey occurred just after the beginning of the new fiscal year, the plan of care did not reflect all the monitoring systems and other changes that had been put into place, he explains. In addition, the new manager of the area had not had an opportunity to critically review the document. These findings caused the surveyors to dig further into other areas and processes, with stringent review of other plan of care summaries and budget documents, Boucree adds. "It was particularly uncomfortable since this occurred on the first day of the survey after the document review."

The surveyors accepted the explanation and the supplemental documentation which demonstrated compliance, but the seemingly simple inaccuracies could have caused a significant problem, he says. This was a critical lesson that was learned, says Boucree. "As we do last-minute preparations and changes of the guard, senior administrative oversight becomes even more imperative, to ensure that there is document accuracy so as not to provide misinformation which has to be corrected and backtracked."

(For more information about the facility’s Joint Commission survey, contact:

Michael Boucree, MD, Vice President for Medical Affairs, Hurley Medical Center, Flint, MI 48503. E-mail: