Accreditation Field Report: JCAHO impressed with internal transfer
JCAHO impressed with internal transfer
Surveyors liked evidence of reduced handoff errors
During an April 2005 survey at Fort Sanders Sevier Medical Center in Sevierville, TN, JCAHO surveyors used the Survey Activity Guide (SAG) as their own guide for every system tracer they did, reports Nancy Van Voorhis, RN, CPHQ, manager of quality and clinical care. "As we sat down at the system tracer sessions, the surveyors would pull out their SAG section on that system tracer. So my best advice is to use the Survey Activity Guide for your prep tool. We did, and we did fine."
Here are key points of the survey:
• Surveyors wanted to know what was done in response to data.
"They want to see evidence that you are doing something with the data — not just collecting and analyzing but that you are actually taking action on the things you are finding," she says. "We shared information on things we had improved on and also let them know that there were things we had worked on that didn’t always work."
For instance, a pneumococcal vaccine protocol has worked extremely well. "On the other hand, we, like many others, continue to struggle with documentation of all the components for written discharge instructions for heart failure patients."
Van Voorhis kept separate notebooks with the required information for core measures.
"We were advised to only provide information as they requested it, not to leave manuals of data and minutes at their disposal. We had worked with our local quality improvement organization [QIO] on core measures projects, and I put a manual together with our results as a hospital to show how we compare nationally and statewide. They really liked that," she says.
Van Voorhis also included the PDCA (plan, do, check, act) work done with the QIO projects and several other performance improvement activities being monitored, such as ongoing medical record reviews and staffing effectiveness.
• Surveyors liked the organization’s internal transfer sheet.
"The surveyors indicated the most mistakes happen during handoffs and inquired what we are doing to prevent these mistakes," she says.
An interdisciplinary form is used with all the information that would be given in an oral report, so the person receiving the transfer has this for quick reference and doesn’t need to write it all down. "It doesn’t substitute for the oral report, but it complements it," Van Voorhis notes.
• Use of range orders for medications was discouraged.
Surveyors wanted to see that policies existed to give clear guidelines for medications given for mild, moderate, and severe pain, and a specific indication for the purpose of the medication, such as pain or nausea. "The idea is to take out as much guesswork as possible for the nurses," says Van Voorhis. "It should not be at the discretion of the nurse. The nurse should have definite guidelines for what to give."
• Surveyors attended an interdisciplinary discharge planning meeting.
She invited surveyors to one of the organization’s discharge planning meetings. The meetings are held twice weekly and include the hospital chaplain, respiratory therapist, coder, pharmacist, physical therapist, dietitian, case manager, utilization manager, infection control nurse, and staff nurses.
"We meet and discuss discharge planning needs for all patients to address what help is needed. After attending the meeting, the physician surveyor indicated he rarely has a chance to see the interdisciplinary process in action. They never asked us one more thing about interdisciplinary communication or documentation of interdisciplinary care plans, because they saw our plans in action. It was probably one of the most useful invitations I’ve ever extended to anyone."
[For more information, contact:
- Nancy Van Voorhis, RN, CPHQ, Manager, Quality and Clinical Care, Fort Sanders Sevier Medical Center, Sevierville, TN 37862. Phone: (865) 429-6578. E-mail: [email protected].]
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