Tales of JCAHO: Prepare your staff to be quizzed about employee health

Will your hospital be one that gets grilled?

If you have a Joint Commission survey coming up, be prepared for this: Surveyors asking employees (not you) about follow-up to needlesticks. Surveyors asking for compliance rates of TB screening. Surveyors looking at your injury logs. The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has an overriding focus on patient safety, but employee health is increasingly being swept into that scope of questions. Some employee health professionals are feeling the impact of the Joint Commission’s partnership with the U.S. Occupational Safety and Health Administration (OSHA).

Taking a closer look at injuries, problems

"They’re looking much more at actual injuries and actual problems," says Steven Weiner, FNP, MS, MPA, clinical manager of the employee health service at New York University Medical Center in New York City. "This alliance with OSHA is important."

At the same time, "it is extremely variable," says Geoff Kelafant, MD, MSPH, FACOEM, medical director of the occupational health department at the Sarah Bush Lincoln Health System in Mattoon, IL. He also is chairman of the Medical Center Occupational Health Section of the American College of Occupational and Environmental Medicine in Arlington Heights, IL.

At one hospital, employee health professionals may sit in on the infection control and environment of care meetings with scarcely a comment to make. At another, a surveyor may pour through injury records and send employee health staff scrambling for more data.

One trend affects all departments of the hospital, according to Patrice Spath, RHIT, a health care quality specialist with Brown-Spath & Associates in Forest Grove, OR: Surveyors are talking directly to employees. "If the surveyors want to know about the process for handling needlesticks, the employee health nurse probably knows exactly what the process is," she says. "But does the staff person in the emergency department whom the surveyor asks know the answer?"

Based on their recent training or background, surveyors may have certain areas they emphasize. "There are ways of finding out what the interests of a particular surveyor are [from their prior surveys]," notes Kelafant.

But one caution in trying to deduce a "favorite" topic of a surveyor: That person may have focused on one area at a hospital because of a special circumstance there. The surveyor’s next encounter may take a completely different direction, says Spath. While surveyors may have a particular interest in certain areas, they all will be concerned about patient safety. Links between worker and patient safety, such as improving patient transfers, will resonate, says Spath. "I encourage employees instead of saying, We’re improving quality,’ to say, We’re improving safety,’" she says. "The word safety is a key word surveyors like to hear."

Several employee health professionals offered to share their experiences in recent surveys:

Surveyor sends EHP scrambling for data

Performance improvement became a focus of a surveyor’s questions at New York University Medical Center, according to Weiner. "We had a performance improvement team that focused on body fluid exposures, and we adopted two safer devices: a butterfly blood collection device and an IV catheter. She wanted to be sure there were people from different disciplines on the team. Once we were able to show in a couple of questions that we had what [the Joint Commission] wanted [for evaluating exposures and seeking safer devices], that was the end of it.

"We also had been working on improving data collection and compliance rates with tuberculosis skin testing. That effort had been mentioned in the infection control committee minutes. I was very happy with the improvement. She wanted to know if we were saying there is an improvement, what were the baseline rates? Also, she looked at the rates for every department. We have a pulmonary function lab that has four employees, and one hadn’t received a skin test. The pulmonary function lab looked like it had 75% compliance, and [the surveyor] wanted to know why.

"It just caused a headache. I had to spend a fair amount of my time looking for statistics. We had a compliance rate of 81% in 1999 and 91% in 2000. Meanwhile, the person in the pulmonary function lab came in an hour early one day and had the skin test.

"For another reviewer, the information in the [meeting] minutes might have been fine, but she wanted that level of detail. The surveyor concluded the EHS part of the interview by asking what other issues we were concerned with. I did have the right answer — for the survey and for the hospital — musculoskeletal injuries and ergonomics. It was clear it was an issue we were addressing, and that’s all she wanted to know," Weiner says.

Why one EHP kept hold of the files

Confidentiality is a major issue, says Mary Shock, RN, an employee health nurse at Kettering (OH) Medical Center who worked with four surveyors during reviews of the hospital, home health unit, home infusion, and associated home medical unit:

"If [the surveyors] would start to look through the charts, I would stop them and ask them what they were looking for. Each one was testing me to see if I would stop them. One surveyor called the office, gave me a list of charts he wanted to see, and said he would send a runner to pick them up. I replied, I’m sorry. You cannot do that. I will bring the charts over, but I cannot give them to a runner.’ He asked why I wouldn’t let the runner take the charts. I said, You and I both know you were testing me. I cannot let someone else take the charts because they contain confidential medical information,’" she explains.

"Surveyors also want documentation in each chart that hepatitis B vaccination is offered upon hire and that those taking the vaccine are being sent reminders to come for their scheduled vaccine. When the vaccine was first offered [in the mid-1980s], we were doing mass inservice training for everybody. At the end of the inservice [employees] signed a consent saying they wanted to get the vaccine and report to employee health at their convenience.

"There were a few people who never showed up. We had no follow-through for those people, and [the surveyors] faulted us for that. We should have made [staff] sign a declination [if they weren’t vaccinated immediately]," Shock adds. "I am going through 6,000 charts to see who may have signed the consent and never taken the vaccine. Last spring, we became aware that anyone who had the HBV vaccine needed to have a post-vaccine titer [to detect antibodies to the HBsAg antigen]. We already had begun working on that before the surveyors came. Out of 6,000 volunteers and employees, we’ve probably got 2,000 that need to be titered," she says.

JCAHO wants to see your team approach

Joint Commission surveyors like to see a multidisciplinary, team-based approach to issues, says Patricia Dalton, RN, COHN-S, administrator of occupational health at Pitt County Memorial Hospital (PCMH) in Greenville, NC:

"The surveyors seemed to want to know how we work together across departmental lines. We are very interdisciplinary at PCMH. My department works very closely with safety, infection control, and quality. Let’s say we’re doing an ergonomics analysis in dietary services. We will try to involve the staff-level people in dietary as well as the management," she explains.

"We have an IV access team [looking into safer devices] that includes physicians, nurses, and purchasing staff. A subcommittee of nurses has been observing IV sites to see how many sticks it takes and how often the IVs are switched out," Dalton continues. "We’ve got employees in every department, so we have to relate to those employees, rather than just going in and saying, This is your problem and this is how you have to fix it.’ We’re able to get a lot of different perspectives on the issues and get a better resolution."