JCAHO asks: ‘Is your patient education thorough?’
JCAHO asks: Is your patient education thorough?’
Documentation, interviews, materials are proof
Don’t expect the same old survey when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in Oakbrook Terrace, IL, pays you a visit. Patient education managers are telling their colleagues to prepare for more staff and patient interviews and expect surveyors to look for evidence of patient teaching in a variety of places.
In a survey, there are many ways to determine if patient education standards are being met, according to Carol Mooney, RN, MSN, associate director for JCAHO’s standards interpretation group.
To evaluate patient education efforts at a health care facility, surveyors look at educational materials, signs, and other informational items posted to educate the patient, medical records, physician progress notes, policy and procedure, and patient rights and responsibilities. Also, they interview patients and staff to validate that the process is followed.
Cross-checking provides a clear picture. There may be documentation of interdisciplinary communication and teamwork on patient education, but an interview with a patient or staff member may contradict what was written, says Mooney. Surveyors may find evidence in other areas, indicating the standard is not being met.
How do health care institutions reveal evidence of patient education in all the areas a surveyor might scrutinize? To find out, Patient Education Management asked several who were recently surveyed.
Interviews with staff involved in the day-to-day care provide a lot of information. That is why it is important for patient education managers not only to make sure that policies and procedures for meeting patient education standards are in place, but that staff are aware of the policy and how the institution meets the standards, says Karen Peterson, RN, MSN, patient education coordinator at All Saints Healthcare in Racine, WI.
To make sure staff understood how they were meeting patient education standards in ambulatory care areas, Peterson educated them on the assessment and teaching process in that setting before the health care facility was surveyed in December 2001.
Patients fill out a history form that includes questions about cultural and educational issues. Physicians then provide the main patient assessment and record their education in the progress notes. "Before this education effort, if someone would have walked in and asked how we do patient education, staff probably would have given them a blank stare. I helped them understand how they were meeting the standards," says Peterson.
To educate staff throughout the institution, an employee handbook was published that highlighted areas of the chapters on patient education standards that were important for staff to know. Helping to define how staff met the standards was important, she adds.
Joint Commission surveyors interviewed patients and staff on more than 20 units at Jackson Health System in Miami. In preparation for anticipated interviews, the hospital gave employees tips on complying with the standards and included questions and answers in the employee newsletter. They also did mock interviews every week for a year where an internal survey team asked staff questions based on the standards.
During the March 2002 Joint Commission survey, surveyors asked staff how they got patient education materials approved and what the process was, recalls Sharon Sweeting, MS, RD, LD, CDE, patient and family education coordinator at Jackson Health System. The staff preparation proved worth the effort because they knew that clinical educators distributed materials approved by the patient education committee to units, service areas, and clinics. They also knew that the hospital had many patient education materials on the Internet, and patients could access the information on their own, she reports.
At Southwest Washington Medical Center in Vancouver, surveyors asked staff if patients were asked about over-the-counter medication use including herbal medications and if patients were educated accordingly. They also asked how patient’s pain was assessed when the patient was unable to speak or if he or she was an infant or small child, according to Cindy Eling, RN, Donna Bashwiner, RN, and Christine Bolger, RN, three nurses from the quality department that accompanied the JCAHO survey team in January.
In preparation, staff were trained to answer such questions about patient care and treatment during mock surveys. They also were required to complete chart audits so they could see what was expected and what was missing when documenting patient education, says Mary Paeth, MBA, RD, patient/community education coordinator at Southwest Washington Medical Center.
The education department also conducted chart audits and rewarded staff for documenting patient education. In addition, they used a Jeopardy game show-style format in a skills-fair setting to ask JCAHO questions and review answers. (For information on using rewards to improve documentation, see Patient Education Management, May 2002, p. 57. To learn more about Jeopardy-style games to teach Joint Commission standards, see PEM, May 2002, p. 55.)
The search for evidence
To conduct patient and family interviews at Jackson Health System, the surveyor met with the patient care team and asked them to present the case. The cases sometimes were selected by staff, and other times the surveyors randomly pulled charts. A frequent question asked of patients was: "Were you taught how to take care of yourself? And if you were, what was the most important thing you learned?"
While patient and staff interviews seem to be an important piece of the current survey process, remember that evidence of patient education must be found in many components. Therefore, the use of forms can provide evidence that standards are being met.
At Jackson Health System, the use of patient education protocols has helped to provide evidence of interdisciplinary team planning and documentation. The forms have educational content down the left of the page and resources for teaching across the top. The 54 diagnoses-specific forms were created for standardization to ensure that everyone covered the same information, says Sweeting. They have been well received by the Joint Commission.
A one-page interdisciplinary documentation form provides evidence of communication at Southwest Washington Medical Center, says Paeth. However, according to Mooney, while there must be evidence that there is interdisciplinary coordination and collaboration, documentation does not have to be on one form.
"Nursing might be the primary discipline over patient care, but there must be evidence that other disciplines are part of the education and nobody works in isolation," she explains. For example, if a registered dietitian instructs a patient, there needs to be evidence that the nurses caring for the patient know what the patient was taught.
"What we heard over and over is Where can I find the story of the patient?’ They didn’t say that we had to have a multidisciplinary form; they just asked to see the story of the patient," says Sweeting.
Because documentation was not in one place, the education department developed a new tab for education in the inpatient record where any forms that have education in the title are to be kept, including the education summary, patient education protocols, and clinical pathways with an education component. While the system had not yet been implemented at the time of the survey, the fact that it was ready to put into place satisfied the survey team.
Materials can be used as evidence of the education process as well. A handout at Jackson Health System shows the integration of patient safety with patient education. Five Steps to Safer Health Care, published by the Agency for Healthcare Research and Quality in Rockville, MD, is available for every patient. It includes such information as "Make sure you understand what will happen if you need surgery," and "Talk with your doctor about options."
The Patient Bill of Rights, written at a fourth- or fifth-grade literacy level, is posted throughout the hospital, says Sweeting.
A TV Guide/Patient Handbook at Southwest Washington Medical Center contains general information on patient safety and patient rights and responsibilities. "We use that as our general information. Specific information, based on patient condition and treatment, is handled individually," says Paeth.
It also is important to have evidence of real-life outcome measures to show the value of patient education, says Sweeting. When a surveyor asked her how she was able to justify patient education in terms of outcome measures, Sweeting was able to tell him about a diabetes self-management program the hospital created that was adopted as an HMO member benefit. "We showed them that we could decrease the amount of emergency department visits their clients would have if they went through the program. The surveyor wanted real-life outcome measures, not clinical academic measures," she says.
Sources
For more information about the patient education focus of Joint Commission surveys, contact:
- Carol Mooney, RN, MSN, Associate Director, The Standards Interpretation Group, JCAHO, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5005.
- Mary Paeth, MBA, RD, Patient/Community Education Coordinator, Education Department, Southwest Washington Medical Center, 400 N.E. Mother Joseph Place, Vancouver, WA 98668. Telephone: (360) 514-2230. E-mail: [email protected].
- Karen Peterson, RN, MSN, Patient Education Coordinator, All Saints Healthcare, Education Resources Dept., SMMC, Racine, WI 53405. Telephone: (262) 687-4246. E-mail: [email protected].
- Sharon Sweeting, MS, RD, LD, CDE, Patient and Family Education Coordinator, Department of Education and Development, Jackson Health System, Jackson Medical Towers-7th Floor East, 1500 N.W. 12th Ave., Miami, FL 33136. Telephone: (305) 585-8168. E-mail: [email protected].
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