Accreditation Field Report: Surveyors quiz staff with their own prep tools
Surveyors quiz staff with their own prep tools
Survey team thorough with the basics
During a recent JCAHO survey at McKay Dee Hospital Center in Ogden, UT, surveyors used the organization’s own preparation tools to interview staff. "We made JCAHO booklets, and the surveyors asked clinicians questions right out of them, saying, So what haven’t I asked you out of your book?’" says Bonnie L. Jacklin, RN, MS, nurse administrator.
Similarly, when surveyors wanted to know how communication from leadership got down to the staff level, they used the organization’s own newsletters, flyers, and memos to assess this. "If they saw something laying around, they would just pick it up and read it — including memos they picked up in our break room," says Jacklin. "If they saw something sitting there, they figured it was fair game."
The survey team was very thorough with the basics, looking closely at history and physical, nursing assessment, care plans, pain assessment, medication orders, and processes for verbal orders, says Jacklin. "They would spend from a half hour to three hours on a unit looking at processes," she says. "By the fifth day, we could predict what the surveyor was going to ask for, depending on what they saw during the tracer."
Surveyors were very interested in communication between clinicians and other departments or physicians and spoke with all disciplines that cared for the patient being traced. They also wanted to know how the organization’s board members interacted with staff, and how much access staff had to the board.
"They were impressed with the participation of our board members during the survey," she says. "The surveyors were very impressed with our quality reports and how we reported to both the board and staff with the same report."
Quality data are gathered on a monthly basis, and each service line presents its reports quarterly to its departments, the medical executive council, and the quality oversight council. "The quality oversight council includes the medical director and the chief nursing officer," Jacklin explains. "They take these quarterly reports to senior management and the board."
The hospital received only minimal recommendations for simple processes that were not followed completely, such as obstetrics anesthesia using an abbreviated form for history and physical. "This was not acceptable, so we changed to the existing OR anesthesia form, while JCAHO was still here," says Jacklin.
"It is harder to prepare for this type of survey because we could not hand pick who the surveyor would talk to and prep them," says Jacklin. "We had to rely on the staff to retain the information that was given to them through staff meetings, newsletters, and inservices. Not having control was hard, but our staff did great."
Here are questions asked by the surveyors:
- For patients transferred from other facilities, surveyors wanted to know how the transferring hospital communicated with the receiving hospital. They asked nurses how they knew the patient was coming and whether communication between nurses was face-to-face or over the phone.
- They asked about communication during patient handoffs, such as how patient information was passed on to the next shift or when patients are transported for diagnostic testing. "They were asking a lot of questions pertaining to that and said it would be a great thing to do an FMEA on," she says. The organization uses a transfer form when patients are sent to different units, to ensure a standardized process for handoffs.
"Face-to-face communication is always better, but the cath lab may be starting another procedure, so the technician may bring the patient out to the floor," she says. "So we do a lot of communication, and we also use the form. If it’s missing any information, nurses do have a chance to ask questions." - Surveyors asked about the number of times patients were transferred to different units within the facility. "That’s one way that errors can occur. The way we have it set up is by providing different levels of care in the same unit. We bring the service to the patient instead of the patient going to the service," says Jacklin.
The organization’s cardiovascular thoracic unit provides care to patients that require vasoactive medication, to control blood pressure in patients receiving a pacemaker who will be discharged home in a few hours. - Surveyors looked at the process for verbal orders in every unit. "Our process is that when a nurse takes a verbal order, they write RBO’ for read back order.’ That’s how we audit the process," says Jacklin.
- If the surveyors saw a "prn" or range order for medications, they asked how nurses knew how much medication to give. "We have a very detailed policy for prn and range orders," Jacklin says.
- On the mother/baby unit, surveyors went over security in detail. "They really delved into it - it was so intense," says Jacklin. "In previous surveys, they just skimmed the surface. But this time they kept delving deeper until they had no more questions to ask," she says.
- In the neonatal intensive care unit, surveyors wanted to know the process for when the mother was being discharged but the baby was not and chose a patient who lived 100 miles away. "They wanted to know how social work and dietary was involved and spent quite a bit of time on follow-up," she says. "They wanted to see evidence of multidisciplinary care, including psychosocial elements."
[For more information, contact:
- Bonnie L. Jacklin, RN, MS, McKay-Dee Hospital Center, McKay-Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-3295. E-mail: [email protected].]
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