ED Accreditation Update: Joint Commission surveys: It’s a brand new world

How can you best prepare and educate your emergency department staff?

As an ED manager, you may be accustomed to handling the brunt of responsibility for accreditation surveys. But under the new Shared Visions — New Pathways process from the Joint Commission on Accreditation of Healthcare Organizations, surveyors will be talking with your staff and your patients. How on earth can you prepare for that?

Learn what to expect from ED managers who have undergone surveys under the new process. Pattie Walker, RN, director of the emergency service at Mercy Hospital Grayling (MI) shares this insight:

"There was less focus on policies and procedures and more focus on looking at patient records, talking with staff, and talking with patients and families about their care experience."

Here are some specific expectations you should have:

• Patients are likely to be traced to the ED.

Under the new tracer methodology, surveyors may pull an ED patient’s chart and trace that patient’s care, including any ancillary services, or they may pull an inpatient’s chart and trace that patient’s care back to the ED.

At Mercy Hospital Grayling, five ED patients were traced.

"They actually did have a patient chart, but they came and asked about that patient type rather than a specific patient," Walker says. "They asked, What is your plan of care for a patient with that type of diagnosis?’ They wanted to know how the patient would be referred there, how we would share information, and how would we determine a plan of care."

Surveyors went to the ED at Trident Medical Center in Charleston, SC, four times, says Tom Rounds, director of emergency services.

Surveyors wanted to know how ED nurses would know a patient had a living will, he says. Surveyors toured the department and asked to see where patients arrive. As they passed equipment, they checked to see when it was inspected. They asked what information is shared from EMS at the bedside and how the family is included in the history and evaluation of patients, Rounds explains.

Surveyors also may ask about ED care outside of your department. At Froedtert Hospital in Milwaukee, surveyors asked a floor nurse about communication from the ED, how report is handled, and where the ED records were in the chart, says Jody Jesse, RN, director of the ED.

"They looked thoroughly at completeness of documentation, informed consent, conscious sedation, and consent for treatment," she says. "Then they came to ED to have a tour and asked the staff RN the same questions about continuum of care."

• Patients will be interviewed.

At Norton Suburban Hospital in Louisville, KY, surveyors quizzed patients who had been admitted though the ED about whether their ED experience was positive, says Heather Cote, RN, BSN, MBA, chief nursing officer and vice president for patient care.

"Our clinical care is sound, so [surveyors] wanted to know if the patients felt comfortable, did they feel they were seen in a timely matter, were their needs met, was it a positive interaction with staff and physicians, were they notified and involved in decision making, and did they know the reason for their admission," Cote says.

Also, patients were quizzed about their transfer from the ED to the floor and whether the person transporting them talked to them, she says. "They want to know patients are involved and informed about their care," Cote says.

• Surveyors will interact with your staff.

Typically, staff members are asked about the patient care they provide.

At Trident Medical Center, an ED tech was asked about credentialing and how he was qualified to be part of the team.

At Froedtert Hospital, surveyors quizzed a second-day RN orientee about the nurse’s previous experience, the orientation schedule, and why the nurse decided to work at Froedtert Hospital, Jesse says.

Keep in mind that surveyors can ask about general hospital policies, Cote warns.

They can ask, What’s the visitor policy for the hospital vs. your department?’" she points out. "Even if we don’t know the hospital policy backward and forward, we can say there is a definite visitor policy given upon admission, and it’s part of the admission assessment."

• You will be questioned about the national patient safety goals.

Surveyors put a significant emphasis on the national patient safety goals, Cote and others emphasize.

"They really focused in on doing the right things for the patient, such as with medications," she says. "They asked, How do you ensure you’re providing good, safe patient care?’ That’s a thread we saw through the survey."

When asked about safe patient care, staff responded with specifics, such as the fact that two patient identifiers are used, Cote says.

Ensure staff members are familiar with the high-alert medications and list of approved abbreviations, Jesse emphasizes.

What should you do to prepare?

Because of the heavy interaction of surveyors with staff, education is a key element of preparing for the new survey process, ED managers point out.

At Norton Suburban, managers educated staff on the national patient safety goals and the terminology that surveyors use, Cote says.

The education was done informally at staff meetings and on bulletin boards, which listed the goals and terminology, she says.

At Paradise Valley Hospital in National City, CA, the managers ensure staff members understand the department and hospital’s mission, says Stephanie J. Baker, RN, BSN, CEN, MBA/HCM, director of emergency services.

Also, new and current staff members are given an explanation of the tracer methodology and told what questions to expect, she says.

In addition, the hospital’s director of performance improvement puts out a weekly publication called JCAHO Express News. This one-page sheet has covered, for example, the patient safety goals and what the hospital is doing to meet each goal. The sheet is posted in the lounge and discussed at change-of-shift meetings, Baker says.

Also, managers have ensured that employees have access to the Joint Commission publications and web site, www.jcaho.org, she explains.

At the ED monthly staff meeting, the manager selects a patient to trace and ask questions.

Baker says, "For example, if the patient was in restraints, I’ll say, Bill, tell me about your restraint policy. How can I be sure you’re competent to put restraints on and monitor patients? How do you assess when a patient’s ready to come out of restraints? How do we determine whether it’s medical or behavioral restraints?’"

Baker asks about patient rights for those who are put on involuntary hold. Other staff members can interject answers.

And tell your staff to relax, managers emphasize. "I felt the way the surveyors asked the questions was very nonintimidating to staff, so it really put them more at ease," Jesse says.


For more on the new survey process, contact:

  • Stephanie J. Baker, RN, BSN, CEN, MBA/HCM, Director, Emergency Services, Paradise Valley Hospital, National City, CA 91950. Phone: (619) 470-4386. E-mail: StephanieRN1@cox.net.
  • Heather Cote, RN, BSN, MBA, Chief Nursing Officer, Vice President for Patient Care, Norton Suburban Hospital, 4001 Dutchman’s Lane, Louisville, KY 40207. E-mail: heather.cote@nortonhealthcare.org.
  • Pattie Walker, RN, Director, Emergency Service, Mercy Hospital Grayling, 1100 Michigan Ave., Grayling, MI 49738.