Accreditation Field Report - Medications, life safety are focus during survey

A recent Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey at Medical City Dallas Hospital was "extremely educational," with surveyors taking extra time to educate staff, reports Rosemary Rouse, RN, BSN, the organization’s survey coordinator.

"Staff were more comfortable with this type of process because it focused on how their roles impact patient care. They were able to elaborate about the things they do every day."

Before the survey began, surveyors announced they wanted the process to be a partnership and an educational experience for everybody, with the focus being on patient care as opposed to policy review, Rouse adds.

Here are key areas of focus during the survey:

  • Environment of Care and Security.

Surveyors incorporated Environment of Care evaluations on every unit they visited, continually checking for safety hazards during patient tracers. "That was different — in the past, that was not as much of a focus," she adds. For example, during a patient tracer, a surveyor would go into a room, check the intravenous pump, and ask to see the maintenance history on that pump.

Surveyors also looked for compliance with new Environment of Care standards related to controlling egress, Rouse explains. "They spent time in the newborn and pediatric areas looking at the entry and exit ports to assess how well they were secured, the alarm sensitivity, and who had access to certain elevators," she says.

The focus was on making sure pediatric populations were secure. "For areas with camera-monitored access, they checked to see that it was monitored 24 hours a day, seven days a week, to ensure the safety and security of patients."

  • Medication management.

"The medication management standards seemed to be a big focus area, and they reviewed this on every unit they visited," Rouse notes.

Surveyors reviewed the pharmacy’s overview of medications before they were administered, pain management, documented need for a medication in the record, and unapproved abbreviations, and asked about the read-back process for verbal orders.

The surveyors also looked at how pain management orders were written and how nurses selected the appropriate medication to give if multiple orders were present.

"For example, if a nurse had two pain medication orders, they wanted to know how the nurse made a decision to choose one over the other," Rouse says.

  • Communication.

Surveyors wanted to know how patient information got communicated from one shift to another, or one discipline to another, to ensure a smooth continuum of care.

"They would follow a patient down to radiology for a CT scan and monitor to see what information was transferred from point A to point B," she explains. For example, they wanted to see if the patient record and orders went along with the patient, and if the orders were reviewed prior to doing the procedure.

  • Physician documentation.

The physician surveyor did pull charts to assess handwriting legibility, but there was always a nurse who could read or interpret the physician’s writing, Rouse says.

"The surveyor’s definition of legibility was that somebody who didn’t read it every day would be able to read it quickly to promote patient safety," she notes.

If the surveyors found charts missing an element of documentation, they would ask for additional charts from medical records to make sure they had an adequate sampling.

"If everything looked good in those records, then everything was fine," Rouse adds.

[For more information, contact:

Rosemary Rouse, RN, BSN, Survey Coordinator, Medical City Dallas Hospital, 7777 Forest Lane, Dallas, TX 75230. Phone: (972) 566-5861. Fax: (972) 566-4697. E-mail:]