ED Accreditation Update

Surveyors scrutinize patient rights compliance

Pain management is just one focal point

Do you work on decreasing your turnaround time by faxing the delayed nurse report rather than calling upstairs? If so, is pain assessment on there?

"It should be, because [the surveyors] are going to look for it," says Eileen Whalen, MHA, RN, vice president of trauma, emergency, and perioperative services at University Medical Center in Tucson, AZ. Whalen spoke at the last leadership meeting of the Emergency Nurses Association.

Even better is to include the last dose of analgesics, Whalen adds.

The Joint Commission on Accreditation of Healthcare Organizations is paying particular attention to pain management in the ED, Whalen says. For example, EDs can be cited for failing to reassess pain, she points out.

Other critical areas of compliance with patient rights standards in the ED include:

  • Patient rights statement.

Have a copy readily available to your patients as they come into that emergency department, Whalen advises. "Many of you probably have that in your admission packet, but patient rights have to be readily available to every patient," she says. Post them, and ensure they spell out that patients are included in decision making.

  • Admission criteria.

Many ED managers think it’s preposterous to have admission criteria in an ED because they take every patient who comes in the door, adds Whalen.

"Well, you don’t keep everything that comes in the door," she points out. For example, patients may be transferred to a higher level of care. "That should be documented in admission criteria," Whalen says.

Many hospitals already have admission criteria in their scope of service document, she points out. "It’s OK to say My admission criteria are included in my scope of service document,’" she advises.

  • Appropriate communication.

The standards point out that patients have a right to appropriate communication, and one potential problem area comes up with patients who don’t speak English or aren’t able to communicate well with providers, says Amy Wilson, MPP, CPHQ, associate project director at the Joint Commission.

In addition, patient rights statement should be posted in all the appropriate languages, sources say.

  • Informed consent.

EDs are expediting patients to the catheterization lab for definitive treatment, but what type of informed consent is the ED patient getting? asks Whalen.

Surveyors will ask your staff about doing the informed consent on emergency catheterization procedures, she warns. "And that’s just one example," Whalen adds.

In doing the tracer methodology, if a survey says that a patient had a procedure in the ED, they’re going to go look for that consent, she continues.

However, EDs can have blanket policies about what procedures you consent and what procedures you don’t consent, she advises.

"Make sure you know those policies, so if they come up with one you didn’t have to consent, you can answer, Oh, you’re not going to find a consent on that patient’ for whatever reason," Whalen notes.

  • Advanced directives.

One problem area for EDs is lack of respect for patient wishes regarding do-not-resuscitate orders.

Clinically, you need to know if the patient is a no code, she adds.

Also, for every admitted patient, the hospital has to ensure there’s information about advance directives on that chart. "It starts in the ER," Whalen explains. "It starts at those outlying facilities that transfer into your mother ship.’"

You don’t need to conduct a detailed interview with the patient, she says. "It’s information about the advance directive," Whalen adds.

  • Denial of treatment for financial reasons.

The Joint Commission has the right to examine your patient records to ensure the ED is complying with the Emergency Medical Treatment and Labor Act.

  • Access to bioethics committee.

One final tip from Whalen: Ensure your staff know how they can access a bioethics committee for any issue. "Whether or not they’ve ever been to a bioethics committee, they need to be able to articulate those answers [about how to access them]," she advises.


For more information on complying with patient rights standards, contact:

  • Eileen Whalen, MHA, RN, Vice President, Trauma, Emergency and Perioperative Services, University Medical Center, P.O. Box 245128, 1501 North Campbell Ave., Tucson, AZ 85724-5128. Phone: (520) 694-4055.