An update on JCAHO: What you need to know to prepare for your next survey

Changes in standards include restraint and reporting of sentinel events

There are several changes in JCAHO standards that you may not be aware of, says Gloria Bower-McLaughlin, a Claremont, CA-based health care consultant. "As an ED manager, you are responsible for the integration and coordination of your accreditation preparation activities with the entire hospital, so it’s imperative you keep up-to-date," she stresses. Other changes in JCAHO standards for the ED include changes in the time frame for reporting sentinel events and using medical/surgical restraint policies.

There are several ways to remain informed about new developments. Use JCAHO’s quarterly updates, new monthly newsletter, information hotline, and Web site to keep abreast of changes in the standards, urges Bower-McLaughlin. "You must embrace the JCAHO standards, creating an environment where preparation efforts and compliance with the standards are systematically integrated into your daily activities and where all staff members are educated and participate in the process," she recommends.

Here are updates of JCAHO standards and "hot button" issues which are currently under surveyors’ focus:

Time frame for reporting sentinel events

The time frame for reporting was recently extended from within 30 days from date of occurrence through date of awareness, to 45 days. "You should do an intensive assessment of any adverse event," recommends Elizabeth DiGiacomo-Geffers, RN, MPH, CNAA, a health care consultant based in Trabuco Canyon, CA. "You should consider doing a root cause analysis, which includes looking at systems, processes, and outcomes. If you do intensive assessments routinely, you will be far ahead of the game in terms of correcting a system."

Assessments of sentinel events should be a multidisciplinary process, DiGiacomo-Geffers advises. "Realize that it’s never one person or thing that causes an adverse outcome, it’s a multitude of things," she says.

Since the root cause analysis focuses on systems and processes rather than individual performances, successful completion will include an action plan that identifies how to reduce the risk of similar events in the future, advises Bower-McLaughlin.

She suggests that measuring the effectiveness of the root cause analysis can be accomplished by asking and answering the following questions:

    • Have the processes and systems been improved to reduce the risk of sentinel events?
    • Are staff able to perform the skills more safely and effectively?
    • Is further improvement necessary?

"If the questions are answered through formal quantifiable measurement methods (e.g., direct observation, individual interviews, or skills assessments) the patterns of performance can be trended and communicated [to the surveyor]," says Bower-McLaughlin.

A credible root cause analysis takes time to complete, DiGiacomo-Geffers notes. "You will find the first one very time consuming, but it gets easier. Practice makes for a much more credible analysis," she advises.

All ED staff should know whom to contact in case of a sentinel event, says Sue Dill Calloway, BSN, RN, MSN, JD, director of risk management for the Ohio Hospital Association in Columbus. "This is key, because there are only 45 days to do a thorough and credible root cause analysis, which is a very short time frame," she says.

Since January 1995, the JCAHO has reviewed 441 sentinel events, 84% of which were self-reported by the facility. "Others are reported through the media, HCFA, patients or their families, or are discovered by surveyors during a survey," Bower-McLaughlin explains. "The ED reports 2.7% [of JCAHO-reported sentinel events], which is significant considering the number of hours patients are in the ED as compared with inpatient days."

Don’t ignore near misses, which include risk of anticipated death or permanent illness, DiGiacomo-Geffers stresses. "A patient may have been given 10 times his or her dosage. Maybe because the patient was an adult, it didn’t kill him or her but it extended the length of stay. However, if the patient had been a child, it could have caused permanent injury and/or death," she explains. "This type of occurrence requires an intensive assessment, including a root cause analysis."

New restraint standards

The JCAHO has approved new standards for restraints, effective as of Jan. 1, 1999, reports DiGiacomo-Geffers. "The medical/surgical standards for restraint now apply to patients in the ED. Even if the patient has a psychiatric condition, until the patient is admitted, the medical/surgical standards apply while the patient is in the ED," she says.

Before the standards were changed, the behavioral health standards applied for patients with psychiatric diagnoses, notes Pat Staten, RN, MS, associate director of the department of standards and interpretation at the JCAHO. "If the patient came into the ED and had a psychiatric diagnosis, they had to comply with the more vigilant standards for the inpatient psychiatric unit," she says. "Now the behavioral health standards don’t apply until the patient is actually transferred to the inpatient behavioral health setting and has a confirmed diagnosis."

Under the old standards, if the patient had a previous psychiatric diagnosis, there was ambiguity about which restraint standard applied. "Before, if a patient had a history of mental illness, there was deliberation about whether the ED should be complying with the more vigilant standards, such as monitoring every 15 minutes, and so on," says Staten. "The final determination was made that all patients would be under the medical/surgical restraint and seclusion standards until they leave the ED."

Under the behavioral health standards, the [patient’s] physician must be notified within an hour, but under the medical/surgical standards, the time limit is 12 hours, Staten notes.

The new standards are less restrictive, DiGiacomo-Geffers says. "They are easier to comply with, but you need to follow the standards to a T,’" she stresses.

Nurses can initiate restraints and get an order later. "This is a good thing, because nurses can initiate restraints in an emergency," says Dill Calloway. "There may be only one doctor working, or some EDs may not even have 24-hour physician coverage. This could be important because if the doctor is in a code, and the nurse is faced with an erratic patient, this allows the nurse to initiate the restraint and then get an order later on."

DiGiacomo-Geffers advises you to ask yourself two questions when evaluating ED patients for restraint: 1) is the restraint clinically justified?; and 2) is it and medically necessary? "An example is a patient who presents in respiratory arrest who is pulling out tubes. He is intubated and has a Blakemore tube in place. His ABGs and electrolytes are out of the upper/lower limit. This is a patient in which restraints are clinically justified and medically necessary."

If a very sick patient were to pull out either the Blakemore tube, which is preventing him from hemorrhaging, or the endotracheal tube, which allows him to breathe, it could result in death, notes DiGiacomo-Geffers. "It’s a matter of doing what’s right for the patient, versus doing what is right for staff. If you are restraining a patient because you don’t have enough staff, that is not appropriate use of restraints."

Conduct an initial, baseline assessment of aggregate data, then continuously monitor targeted elements, says Bower-McLaughlin. "In the performance improvement process, the goal is to identify and reduce the risks of restraint use. So any alternative strategies or performance improvement processes that address this will be useful," she explains.

Surveyors want to see performance improvement in the ED, DiGiacomo-Geffers explains. A surveyor will evaluate patterns and trends by looking at when you apply restraints, what type of patients are restrained, which shift applies them, and who the practitioner is that orders them.

Also keep in mind that use of restraint should involve multidisciplinary participation. "If the patient behavior has to do with drug interaction, you need a pharmacist and a physician to evaluate and help you set criteria," says DiGiacomo-Geffers. Likewise, occupational therapists can train ED staff in diversional therapy techniques, and physical therapists should give input on range of motion and positioning of patients, she suggests.

Hospitalwide focus for managers

As late as 1995, department managers could prepare their areas of the hospital independently, using their own JCAHO chapter, says Bower-McLaughlin. "Those times are past. Through coordinated efforts, ED managers must participate in the hospital’s preparation activities to assure the standard of care in their area is consistent with the hospital’s standards," she notes. Participate in collaborative performance improvement activities, such as integration of appropriate policies, procedures, and protocols, hospitalwide committees, and networking with other managers, Bower-McLaughlin recommends. "ED managers often feel they have a unique, independent environment, but JCAHO preparation is an area where collaboration is essential,"

Evaluating conscious sedation

EDs are still not monitoring conscious sedation outcomes appropriately, warns DiGiacomo-Geffers. "This is still a hot-button’ topic, because staff aren’t consistently trained and educated. Patients need to be evaluated prior to procedures," she explains. You need to measure outcomes and identify patterns and trends before an injury occurs in the ED.

JCAHO standards do not require that the physician be privileged, or a complete [patient] history and physical be taken; however, that is good practice, says DiGiacomo-Geffers. "It is not required per se. However, competent, trained staff are essential, and an assessment of the patient prior to administration of sedation analgesia is a necessity," she notes.

Your practice must match whatever policies your institution has in place. "If your organization’s policy is to privilege physicians and/or nurses, then you must make sure that your practice follows policy," DiGiacomo-Geffers explains. "If the policy says they must be advanced cardiac life support (ACLS) certified, that is your requirement, not JCAHO’s. But if you define competently trained’ people as ACLS certified in your policy, then a surveyor could validate if staff is ACLS certified."

Surveyors want to see that processes and outcomes are measured. "Someone in the organization must have oversight to look at these outcomes and what you have improved in terms of patient care, as it relates to sedation analgesia," advises DiGiacomo-Geffers. "For example, if patients often require an antagonist following sedation analgesia with Dr. Jones, then how are you looking at the practice, the dosage, and what happens to the patient?"

Knowledge and process deficits both need to be evaluated. "If either or both occur, you may have an adverse outcome," DiGiacomo-Geffers notes. "If somebody lacks appropriate training, then you have a potential for an adverse outcome. Likewise, if the oxygen saturation machine is not working and you have no way to monitor the vital signs during the procedure, you also have potential for an adverse outcome."

Surveyors want to see consistent standards for conscious sedation throughout the hospital. "So if a surveyor goes to the ED, they want to be assured that staff are competent and patients receive the same level of care whether they receive sedation or analgesia in the ED or cath lab," DiGiacomo-Geffers says. "The ED may serve a particular patient population, but they should use the American Society of Anesthesiologists’ (ASA) guidelines for conscious sedation, and have a hospitalwide policy on conscious sedation."

Treating victims of abuse

There are three JCAHO standards that address victims of abuse: 1) the identification and criteria; 2) the evidentiary process; and 3) education and training of staff. "This applies to all health care workers who work in the ED and come in contact with the patient," stresses DiGiacomo-Geffers. "If a transporter takes an elderly patient from ED to MRI and the patient says my son stole my social security check and threatened me,’ the transporter needs to know who to report it to."

Hospitals are responsible for developing criteria for identification of victims of abuse. "Hospital staff must be trained to assess and report, if appropriate, victims of alleged or suspected abuse," says Bower-McLaughlin. These criteria need to at least be addressed:

    • Physical assault
    • Rape or other sexual molestation
    • Domestic abuse
    • Abuse or neglect of elders and children

Other departments may look to the ED for guidance in complying with JCAHO standards for abuse, notes Staten. "This had always been a requirement for the ED, and then it went organizationwide in 1994. Now the standards apply to all patients, not just those that come to the ED. So the ED has been complying with those standards for a much longer period of time," she explains.

Stay informed about standard changes

The Joint Commission created a new, official monthly newsletter, titled Perspectives, which is sent to accredited organizations to give up-to-date news straight from the source, notes Dill Calloway. "The premier issue was faxed to all accredited organizations on January 4th of this year, and eventually will be available via e-mail," she says.

Topics covered in the first issue included a meeting of 700 surveyors to review the changes in the standards for 1999, JCAHO type I recommendations dealing with the Y2K issue; and 1999 random, unannounced survey grid elements.

Y2K preparation and compliance

Standards call for an organizational strategy to address Y2K compliance, says Dill Calloway. "The Joint Commission will simply be determining whether the organization is aware of and planning for the year 2000." she says.

To avoid type I recommendations, take steps to 1) identify and assess the implications of Y2K on your operations, including computer systems, medical equipment and utility systems; and 2) determine whether [vendors] are addressing the Y2K issue, Dill Calloway advises. (See section on recommendations on p. 67.)

Registering patients as organ donors

Beginning Jan. 1, 1999, revisions to the standards require hospitals to make sure they identify a designated, qualified requester for approaching potential donor families. "If you have a death in the ED, not just any nurse can go up to the family and ask about organ donation," Dill Calloway explains. "Now you need to designate someone who has had training, or have the organ procurement agency make a decision about whether it’s appropriate to talk to the family."

Patient privacy issues

Staten says privacy issues are a continued focus of surveyors. "Making sure that confidentiality and privacy is upheld is particularly challenging for the ED because it’s a more open area," she says. "You need to be aware of where a patient may be in proximity to other patients." Ensuring that there is no identifying, clinical information on boards visible to other patients is another part of patient privacy.

It may not always be possible to put patients in a separate room, but staff need to take to give patients as much privacy as possible, says Staten.

Dealing with patient complaints

"It is very important to provide an opportunity for patients to verbalize complaints if they’re not happy," says Dill Calloway. "Now a patient can get on the JCAHO Web site and file a complaint against the hospital on the Internet or can copy the complaint form and fax it to them. There is also a toll-free hotline."

Take steps to resolve patient complaints internally, urges Dill Calloway. "The bottom line is that managers need to be more aggressive with fixing problems. Otherwise instead of complaining to you, patients may go to an outside party like HCFA or JCAHO," she stresses. "Also, if you violate a JCAHO standard and a patient finds out, they can use that standard in a court of law."