Recent hot buttons for Joint Commission

Interdisciplinary approach to education sought

Sometimes, the questions that don’t get asked give you a chance to shine the most when the Joint Commission surveyor comes around to check your patient education system.

That’s one of the lessons patient educators learned during accreditation surveys in 1996 — along with new knowledge they gleaned about "hot buttons" the Joint Commission on Accreditation of Healthcare Organizations have during the surveys.

Documentation of patient education by everyone involved in the patient’s care is one of those unavoidable issues. "The surveyors didn’t care if we had one form for all documentation of patient education as long as all disciplines knew where others documented education," says Megan O’Conner Finch, RNC, MS, patient education coordinator at Union Hospital in Terre Haute, IN.

There were other hot buttons patient education managers noticed during the 1996 surveys of their health care organizations. Following are their observations of what the surveyors focused on in the area of patient education:

Assessing for barriers to education.

During the chart review, the surveyor checked to see that anyone teaching the patient had identified barriers to learning before beginning the education session, says Angie King, BSN, director of quality management at Tift General Hospital, in Tifton, GA. The assessment to determine a patient’s readiness to learn should include cultural and religious practices, emotional barriers, desire and motivation to learn, physical and cognitive limitations, and language barriers.

Involvement of community in education programming.

During the interview with the multidisciplinary patient education team at Union Hospital, the surveyor wanted to know how the hospital used community input to prioritize patient education projects, says O’Conner Finch. Team members explained that information is gathered from community surveys initiated by the hospital’s marketing department, satisfaction surveys completed by patients and family members, and surveys participants are asked to fill out at the end of community outreach classes indicating what other programs they would like to see offered. (For information on how the team was used in preparing for the Joint Commission survey and other suggestions on how to be prepared, see story, p. 18.)

Education a team effort

• An interdisciplinary approach to patient education.

When the surveyor pulled together people who were caring for a patient on a certain floor, the surveyor would ask how the various members of the team participated in education, such as the physical therapist or the pharmacist, says Sue Chapman, EDD, director of education and volunteer services at St. Mary’s Hospital in Athens, GA. "We were concerned about having our committee minutes and flow sheets showing how patient education flows from the committee to the staff. Also, how we get data and analyze it in terms of improving our patient education program. The surveyor didn’t look at any of it," she says. Nor did the surveyor interview any specialized educators, such as diabetes or cardiac.

At the University of Wisconsin Hospital and Clinics in Madison, the surveyor wanted to ensure the disciplines understood what each was doing, says Zeena Engelke, RN, MS, senior clinical nurse specialist and Learning Center coordinator. To uncover this information, during the patient education interview of the administrative group, the surveyor asked how a patient’s family is coached during physical therapy to help speed the recovery process. The question considered patient education in an area that was not represented at the interview since the group consisted of representatives from nursing, nutritional services, pharmacy, medical staff, and clinical areas.

Teaching across the continuum of care.

"They would ask a patient in a trauma center about their teaching, and as they traveled through to the step-down and then on to the rehab units, they would see how the teaching traveled across the setting and the awareness of one area to the other area," says Engelke.

If they don’t ask, tell.

If you have something that reflects compliance with the Joint Commission Standards, find a way to offer that information, advises Jeanne Laws, BSN, patient education coordinator at St. Joseph Regional Medical Center in Lewiston, ID.

Although the surveyor didn’t ask, Laws was able to offer an example of how quality improvement impacted the patient education process. When data collected on the use of the housewide closed circuit TV system indicated that people were not using the teaching tool, the patient education department decided to disband the hospitalwide system and provide individual systems on each unit. In that way, staff would have more control over what was shown on their unit, and the material would be more likely to meet patients’ needs.

O’Conner Finch used a similar strategy when putting together the manual for the document review. The surveyors asked for policies and procedures on patient education, but the preparation team decided to include examples to support them. "There is no guarantee that the surveyors will look at something, but we had the material there if they wanted to see it," she says.

[Editor’s note: The structure of the survey depends on how an organization conducts patient and family education. If a multidisciplinary team oversees patient education, an interview would be conducted. If each unit is responsible for patient education, then the surveyor would talk to people on the unit. "Each organization tells us how they conduct patient education, and we plan the survey accordingly," explains Ann Kobs, MS, RN, associate director for Department of Standards Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. For more information write: Joint Commission on Accreditation of Healthcare Organizations, 1 Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 916-5902.]