JCAHO surveys stress Y2K solutions

Millennium mishaps can cause sentinel events

Dwain Shaw, director of information services and Year 2000 project director at the Medical College of Georgia in Augusta, and Wendy Walschlager, RN, director of Health Information at Good Samaritan Hospital in Downers Grove, IL, agree that Joint Commission surveys are focusing strongly this year on year 2000 (Y2K) compliance. Quality professionals have to make sure there are teams in place, that information is being aggregated, and that everyone is up to snuff on progress and process. Walschlager suggests you include some performance measures related to Y2K issues, perhaps on safety-critical equipment such as EKG monitors. She says to anticipate some risk management interaction on the quality end to make sure there’s a plan in place if some of the equipment fails come Jan. 1. "Y2K is a global problem," she says. (See last month’s issue of Hospital Peer Review for coverage of quality assurance’s role in Y2K compliance.)

"Involve everyone in Y2K," says Shaw, a Joint Commission faculty member who has been lecturing on Y2K issues around the country. "Otherwise, you’re not going to be successful. Y2K reaches out and touches everyone." He says the Joint Commission’s main interest in Y2K issues is the extent to which millennium-related problems can cause sentinel events. "If something that we’re aware of causes a sentinel event, it impacts Joint Commission standards in any of three areas — leadership, quality of care, or information management," he says.

Surveyors examine integrity of patient information

In 1998, surveyors asked about Y2K, but it was not high on their priority list. This year, however, surveyors have been trained to look for evidence of strong leadership involvement in Y2K and evidence that preparations have taken place. "They are a little more aggressive this year," says Shaw. "Surveyors are looking at supply inventories and how you’re preparing for your high-demand commodities, particularly life-saving drugs. From the standpoint of information management, God help you if any portion of a patient’s record or other information pertaining to a patient is lost."

He points out that of course the Joint Commission is interested in obvious events, like the power going out, but sentinel events can be caused by unnoticed factors. "The things you don’t think of are going to cause the sentinel event," he says. "If, for example, you think an application is going to give good data output, and it doesn’t, and a drug dosage is in error — that can cause a sentinel event. Every device that produces information needs to be manually checked before patients are affected come New Year’s Eve."

Hospital Peer Review asked Walschlager if quality professionals at a hospital that was surveyed in 1998 should be concerned about Joint Com mission interest in Y2K matters when surveyors return in a couple of years. "Yes," she answers, "because not everything is going to be fixed overnight." The quality process looks at mission-critical compliance first and then at subsequent compliance. "Y2K is an ongoing issue. The Joint Commission will not be so intensely involved a few years down the road; its interest will not be from the perspective of your meeting your mission-criticals, but from the perspective of cleaning up the odds and ends. Surveyors will be asking questions like, Do you have a plan that reflects that cleaning up, and was the plan you implemented successful?’"