Accreditation Field Report: Patient flow, life safety code key topics for survey
Patient flow, life safety code key topics for survey
Unannounced survey is intense,’ detail-oriented
JCAHO surveyors covered far more ground during a five-day unannounced survey at North Shore-Long Island Jewish Medical Center in New Hyde Park, NY, than accreditation inspectors had done in previous years, reports Kerri Anne Scanlon, RN, MSN, ANP, associate executive director of quality management.
"One thing was very clear: If you’re not practicing continued survey readiness every day, you’re not going to do well in this process," she warns. "The surveyors this time around were such seasoned professionals. They were not punitive but were extremely detail-oriented. This is a very intense process — this was a tough survey."
Surveyors were impressed with patient-focused activities held by the organization for National Patient Safety Week. "We did something different this year, by engaging patients and visitors in patient safety," Scanlon says. A table in each lobby featured a raffle with children’s booster seats as prizes, asking the general public for ideas on how to improve safety at the hospital.
In addition, alcohol-free hand-washing gels, information about the Joint Commission’s "Speak Up" initiative, and educational materials on medication management were distributed.
Here are key areas of focus during the survey:
- Medication management.
In all patient care areas, surveyors closely observed how staff administered medications and looked to see if staff were washing hands and complying with infection control standards.
- Patient flow.
"When they did our Data Use interview, they commented that they loved our indicators and what we were looking at," Scanlon says.
Surveyors liked that the organization wasn’t just tracking patient length of stay and the time it takes to get to a bed, but also was looking at clinical indicators that affect patient throughput, such as lab or radiology turnaround.
"When you do tracers, most patients come from the ED [emergency department], so the ED got reviewed more than any other unit in the hospital," she explains. "They were very interested to see how we provided the same level of care
for patients waiting for a bed as we would on a floor," Scanlon says. To address this, inpatient and behavioral health nurses were hired to care for admitted patients being held in the ED.
"We also put in two Six Sigma projects to enhance throughput in the ED with good results, so we were able to identify things that were impinging on moving patients through the ED," she says. "This has been a big priority for our institution. They were very pleased with what we’ve done for throughput. They also liked the fact that we measure those statistics monthly
and that they are reported into our performance improvement program."
Depending on the ED’s volume, green, yellow, and red zones are used to trigger specific interventions to speed throughput. "They loved that — but anything you show them, they want to see how it works," Scanlon explains. "We were able to demonstrate how we provide the same level of care for patients and move them expeditiously through the house."
Surveyors now expect to see patients in hallways, but they want to see that you are doing something to ensure safe care. The organization added a cardiac short stay unit to move telemetry and cardiac interventional patients out of the ED, hired an ED case manager to improve throughput, and hired physician assistants in the ED to provide better care for department of medicine patients waiting for inpatient beds to become available.
- Environment of care (EC).
The EC review was much more in-depth than for previous surveys, says Scanlon. The survey team’s engineer looked at life safety code issues for a full day, but even after that, the EC review was not over, she says. "The administrator surveyor did our two other buildings the second and third day, so we had a three-day EC review, and he also did our EC interview," she notes. "They focused very heavily on infection control and general life safety, fire doors, how we respond in emergencies and disasters, how we chose our drills, and how we responded to them. Almost every unit was asked about life safety code, and it wasn’t just nurses — it was any staff member."
The safety and engineering department collaborated with nursing units to do weekly EC rounds, which prepared staff to answer those questions, Scanlon explains. During the EC interview sessions on the final day of the survey, one of the surveyors shared best practices they had seen nationally.
"They also told us that we should share the results of our FMEA on how to reduce the potential for blood transfusion-related errors with a patient identification process," she reports.
[For more information, contact:
- Kerri Anne Scanlon, RN, MSN, ANP, Associate Executive Director, Quality Management, North Shore-Long Island Jewish Medical Center, 270-05 76th Ave., New Hyde Park, NY 11040. Phone: (718) 470-7825. Fax: (718) 962-6759. E-mail: [email protected].]
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