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Tips from a recent JCAHO survey
[Editor’s note: If your facility recently was surveyed, please contact Staci Kusterbeck, Editor, Hospital Peer Review, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: email@example.com.]
During a July 2003 Joint Commission survey at Childrens Hospital Los Angeles, two areas took center stage: patient safety and performance improvement. "Everywhere surveyors went, they would ask staff what they have done to improve patient safety in the area, and what the area has done for performance improvement," reports Sharon A. Chinn, RN, the facility’s patient care services manager of regulations and outcomes. Here are key points of the survey:
• Surveyors were impressed with the opening conference on performance improvement. The facility had done its homework to prepare, says Chinn. "We took a very proactive approach to that particular conference — it wasn’t just convening the key people in a room and waiting for them to ask us the questions. Our presentation was extremely organized." This paid off because it sent a clear message that performance improvement was a priority throughout the facility, she says.
The facility’s medical director of patient safety and medical director of performance improvement gave detailed presentations on patient safety, which included discussing methodology and philosophy, explaining several programs that were implemented, and giving beginning and ending data to demonstrate specific improvements that were made. Poster boards were made up to display progress with the following areas:
"The room was full of PI boards," says Chinn. "The surveyors told us, You have presented this so thoroughly, we have hardly any questions.’"
• Surveyors asked open-ended questions. "The surveyors didn’t ask leading questions at all; they were looking for very spontaneous answers," says Kathy G. Anderson, manager of medical staff services. "They were fishing to make sure everyone was really involved, to see whether or not the goals had trickled down through the organization."
All patient care areas have dedicated performance improvement information boards, and staff could refer to the data on the boards, she adds. For example, staff in all areas talked about the use of two patient identifiers and could explain how this is tied to safety with regard to processes such as medication administration and procedures. Likewise, surgical staff explained the policy for surgical site markings, and intensive care unit nurses described efforts to reduce noise in the unit so that alarms can be heard over competing noise.
• Educational efforts paid off. "We have done a lot to orient the staff to goals, and that really came out in the survey," Chinn says. "People were very familiar with them." The goals have been stressed facilitywide with the following initiatives:
— Articles in the weekly hospital newsletter cover patient safety on an ongoing basis. In the months before the survey, the six National Patient Safety Goals were featured in six separate issues. The newsletter also included a "JCAHO Q&A Corner," which asked a specific question each week related to overall survey preparation, such as, "If there were a fire in your department, what would be your specific responsibilities?"
1. Patient identifiers: Two required. Inpatient: Name and MR#. Outpatient: Name and DOB.
2. Invasive procedures: Mark the site for right/ left, multiple sites, or level. Have everything needed before start of case, e.g., records, X-rays. Team pauses to verify patient, procedure, and site.
3. Verbal orders: Only in emergencies or when delay would harm patient. Read-back required. In emergencies, repeat back abbreviations.
4. Abbreviations: Use only approved abbreviations. Do not use ara-a, da, nitro, hctz, mr, p-asp, 5fu, 5fc, and cpz.
5. High-alert medications: No concentrated potassium or sodium storage on wards. Double-check with 2 persons. Limit drug concentrations on formulary. Free-flow protection: All intravenous pumps have free-flow protection.
6. Alarms: Routine preventive maintenance. Assure alarm audibility. Never disable an alarm. Respond to all alarms.
• Two Joint Commission fairs were held prior to the survey, from 5 a.m. to 3 p.m. to allow both 12-hour shifts to attend. Nursing staff were required to attend, and attendance was optional for other patient care services staff, including social work, child life, language and cultural services, spiritual care services, pharmacy, nutrition, and rehabilitative services.
At the fairs, staff received intensive education on the standards and how to comply, with booths on the National Patient Safety Goals, pain tools, food/drug interactions, needle safety, information consent/site identification, and "Surviving JCAHO," which gave tips on self-care and stress management during a survey.
The booths were staffed by managers who explained the posted information and answered questions. A test was given to all employees, comprised of questions relevant to each booth. "The successfully completed test was evidence of attendance for the employee’s manager," Chinn says.
• Surveyors wanted to see evidence of a team approach to patient care. Another recurring theme during the survey was an emphasis on interdisciplinary contributions to planning of care, says Anderson. "They wanted to see written documentation of this in the medical record, but they also wanted to hear people talk about it."
When surveyors spoke with staff during chart reviews, they looked for evidence of a cohesive team approach, such as involvement from medicine, social workers, child life, chaplains, diet and nutrition, and rehabilitative services.
The surveyors expected the entire team to convene for the area interviews, and asked questions such as "Go around the table and explain what your role is in the care of this patient."
"Our staff know that all pediatric patients require the same team approach, whether a rehabilitation or transplant patient," Chinn says. "Surveyors were impressed with that."