Accreditation Field Report

Staff preparation pays off during a JCAHO survey

The shared vision of providing safe, quality patient care was very evident during a recent Joint Commission on Accreditation of Healthcare Organizations’ survey at the 59th Medical Wing at Lackland (TX) Air Force Base, reports Lt. Col. Biancanieves Garza, NC, CPHQ, chief of compliance and performance improvement.

"It is clear that the surveyors want to partner with our leaders to attain sustained performance in providing the highest safe, quality care," she says.

To prepare for the survey, staff attended a one-day leadership training program on the new process. They also watched the Joint Commis-sion’s training video "Shared Visions — New Pathways, Innovative Approach to Patient Safety and Quality Improvement," which features numerous examples of actual surveyors using the tracer methodology in different patient care environments.

All unit staff watched a 30-minute segment of the video, which was mandatory.

"The questions used by the surveyors in the video were all asked during our survey, so staff were readily able to respond to the actual surveyor questions," Garza explains.

Focusing on the goals

The organization’s priority focus areas were communication, orientation and training, staffing, and information management.

Surveyors asked to see a chart of a patient admitted or transferred from the emergency department (ED) or intensive care unit (ICU).

"If there were none, they asked for the chart of the most complex patient," she adds.

Throughout the survey, staff were asked how they incorporated the National Patient Safety Goals.

Here are some of the questions asked by the surveyors:

• Surveyors asked to see records to show that read backs are documented for verbal orders and critical lab values.

Surveyors looked for "do-not-use" abbreviations in physicians’ orders and in the progress interdisciplinary notes.

During tracers, surveyors asked what other services were involved in the patient’s care, such as nutrition, radiology, or laboratory.

Surveyors looked for consults ordered and documented findings, wanting to see that orders were reviewed by providers and that providers acted on findings as appropriate.

For patients who were admitted or transferred from the ED or ICU, surveyors asked what kind of communication would be received prior to the patient’s arrival on the unit.

Surveyors asked staff in the ED and ambulatory clinics to describe the process for admitting patients.

Nursing staff were asked to describe how patients are assessed upon their arrival.

During a system tracer, surveyors asked detailed questions about how the organization’s medication management system supports the health care team in providing quality, safe patient care.

"They started the tracers immediately after the initial orientation and continued until the very moment they began to write up their findings," Garza reports. "It was incredible and very exhausting!"

During tracers, surveyors asked staff on duty to talk about what they did in their specific jobs and then followed up with questions such as, "You are a provider? You work in the ED? What training or certification do you need to work here? Do you care for pediatric patients, too? Do you call in consultants?"

The surveyors then moved on to specific patients by requesting a list of patients seen on that day, and asked questions about waiting times, who was called in to consult, how long that individual took to arrive, and what labs, procedures, or radiology tests were ordered.

If the patient was transferred to the operating room, the surveyor would go there and begin the questioning process again, asking questions such as, "What do you do? What do you need to work here? Are you the anesthetist? Tell us what you do once the patient is transferred here. How did the patient get here?"

The surveyor then would ask for documentation such as the ED provider file or ICU nurse’s educational folder and check to see if the laboratory and radiology information followed the patient.

"Everything they did was education in action — it was a reality show,’" Garza continues. "Through example, they showed our staff how the system supports their provision of patient care."

(Editor’s note: The information provided in this article is not intended to endorse any nongovernment organization.)