Here's your frontline report on the Joint Commission survey process
Here's your frontline report on the Joint Commission survey process
Patient rights, staff performance measures scrutinized
The handling of advance directives and patient rights throughout the hospital stay and effective organizationwide communication topped the Joint Commission's list of concerns during a recent visit to UCLA Medical Center in Los Angeles, says Cynthia Frizelle, RN, acting director of admissions and registration.
A grueling few days with surveyors from the Joint Commission on Accreditation of Healthcare Organizations left the admitting department with an increased awareness of its effective processes but challenged the department to improve in other areas, she says. In a more intensive survey than during past visits, admissions staff were "really grilled" on advance directives and patients' rights, she adds. "They wanted to see how the process continues throughout the patient's stay, how the cycle is completed."
Her department demonstrated how it identifies upfront any questions about advance directives and works with patient relations and nursing to make sure the questions are answered. Admitters give patients a pamphlet upfront and then send a printout to the patient relations area indicating patients need follow-up information, Frizelle explains. "If patients need to recreate an advance directive, they are offered information on how to do that," she says. "Then the patient relations person updates the cycle to show the cycle is completed. A copy goes to admissions and is on file in the medical record."
Each time the patient comes in, admitters can see there is an advance directive in the system and send it to the nursing unit so nurses don't have to order the medical record.
She says Joint Commission surveyors were concerned about one other piece of the process: how to get advance directives to the hospital if patients don't bring them. "Sometimes [patients] will put it in a safe deposit box." After the initial inquiry at the time of admission, a member of the admitting satellite team - which is based on the nursing unit - goes to the patient's room to make a second effort to obtain the document. "If nothing comes of that, the patient relations team goes to them and offers to do a new one."
One discovery that came from the advance directive questioning, she says, is that while admitters are knowledgeable about the subject, they need to educate nurses and unit secretaries on how the process works. Sending reminders through e-mail on advance directive procedures is one of the means they'll use, Frizelle adds.
Another innovation resulting from the Joint Commission experience, she says, was the creation of a form, "UCLA Admissions & Registration Nursing Unit Update," that accompanies any changes or updates sent to the nursing units. "It's so they'll know [for example] that this is a new face sheet, how to work with this piece of information that's coming up." (See form, at right.)
Consultants who came in to help the hospital prepare for the Joint Commission visit "showed us we need more collaboration," she says. "People solve problems all the time, but they don't necessarily tell others they've done it or bring in others who need to know."
One of the ways the medical center is facilitating that collaboration is with a hospitalwide performance improvement process called "FOCUS - PDCA," which highlights these points:
o Find a process to improve.
o Organize a team that knows the process.
o Clarify current knowledge of the process.
o Understand sources of process variation.
o Select the process improvement.
o Plan the improvement action.
o Do - Test the action.
o Check - Determine the effects.
o Act - Implement or solidify.
Frizelle says Joint Commission surveyors also devoted significant attention to the issues of domestic violence and elder or child abuse and how the facility handles them. Specifically, surveyors were interested in how staff are informed of such cases and how to report them, she notes.
At UCLA, admission "cheat sheets" placed beside the telephones give employees a quick reference on who to call in such instances. For cases of domestic violence, for example, the contact number of a social worker is listed. As a back-up, staff can call the paging operator, who has numbers for other resources that might be needed.
During its visit to UCLA, the Joint Commission also looked at the following situations:
· How does the facility handle patients in the custody of law enforcement officials.
"They looked at that very closely," Frizelle says. "They wanted to know what processes were in place to make sure everything goes smoothly, how we handle phone calls coming in to find out if the [prisoner or suspect] is here." UCLA has a policy for such situations, including an instructional packet for the law enforcement officer on the hospital's emergency code and phone systems.
If an admissions employee needs help in such cases, there is a protocol to follow, with the name of a person to call first for help and additional contacts if that person is unavailable, she says.
"Certain people in the medical center, like the chief of security, make sure to visit the law enforcement officer to ensure everything is in place, that they know what to do in case of emergency," she notes. "They wanted us to be involved, to make sure we start that process."
· Is there an ethics committee, and how do staff access resources regarding moral and ethical dilemmas they come across during the performance of their jobs?
"[Surveyors] were very interested in how we communicate with staff in a place so large," she says. Employees at UCLA receive information on ethics policies and other issues through e-mail, voice mail, staff meetings, bulletin boards, and one-on-one sessions. Two physicians, available day and night through the paging operator, are designated as ethicists for the hospital. Another resource is a clinical nurse specialist who also is a member of the hospital's ethics committee.
The ethics designation is indicated on these individuals' name badges. However, the Joint Commission suggested a special badge be used so they could be recognized more easily as they walk through the halls, Frizelle says.
· What are the staff training and performance requirements?
"Human resources standards have been increased," she observes. "[Surveyors] wanted not only proof of employee orientation, but identification of competencies for ancillary and nursing services."
In response to this guideline, her department scrutinized performance standards and developed competencies for admitters. (See competency validation checklist, p. 63.) "Everyone had always had a job description and evaluations, but we had never identified exactly what we needed to require and how to measure it or the things employees need to know that don't come up that often. They need to know what to do when it does come up," she says.
Sometimes it's assumed that longtime employees are competent when, in fact, they may not be. "We need to measure them, see if they're at the level they need to be, and if not, determine what we can do to get them there." As a result of the new emphasis, she says, there is now a baseline performance measure in every admitting employee's file.
It's clear that ancillary services such as admitting are becoming more involved in the accrediting process, Frizelle points out, with increasing requirements for standardization and best practice. "It's a lot of work, but I do see the value of it." Going through a Joint Commission visit "proves to you that you have these standards but maybe just didn't put them in writing. It was eye-opening to see that we did have a lot of systems in place."
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