Accreditation Field Report: Surveyors share three best practice ideas
Surveyors share three best practice ideas
Staff at Newport (RI) Hospital were ready when surveyors from The Joint Commission walked in the door, with binders containing current data and all the required documents for the anticipated hot topics: restraints, pain assessment and reassessment, medication reconciliation, and approved locations for moderate sedation.
"Our short introductory presentation of 10 to 15 slides is continually updated, ready for any member of senior management to present at a moment's notice," says Jeanne M. Ehmann, RN, MS, CPHQ, the hospital's director of performance evaluation and improvement.
During the survey, the hospital's CEO was out of town, so the administrator on call and the vice president of nursing and patient care services gave the presentation and led the organization through the survey.
"The confidence in the organization was quite evident," says Ehmann. "The surveyors liked our medication error reporting and analysis process, and our communication for handoffs." The hospital uses the SBAR format for communicating, standing for "situation: background, assessment, and recommendation."
"The life safety engineer was very impressed with all of the hospital safety and environmental reports and rounds," says Ehmann.
Surveyors shared several best practices that they had seen and liked at other facilities. Some examples:
• A format for the hospital's infection control plan.
Surveyors liked a plan that identified prioritized risks, and included the Joint Commission's five pillars: people, changing performance, data, governance, and planning.
• Suicide risk assessment.
The surveyor told staff, "When you assess any room on this unit, you should ask the following question: If I wanted to commit suicide, how could I do it in this room?"
• Pediatric equipment.
The surveyor recommended that emergency equipment in the pediatric cart be color coded to coincide with the Broselow Pediatric Emergency Tape.
"Overall, they were friendly and cordial with the staff," says Ehmann. "They asked questions numerous ways to get to the answer they were looking for, which was helpful for the staff."
Staff at Newport (RI) Hospital were ready when surveyors from The Joint Commission walked in the door, with binders containing current data and all the required documents for the anticipated hot topics: restraints, pain assessment and reassessment, medication reconciliation, and approved locations for moderate sedation.Subscribe Now for Access
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