Accreditation Field Report: Surveyors want to see patient safety culture
Surveyors want to see patient safety culture
Patient flow and life safety code key areas of focus
At a recent five-day unannounced survey at Baptist Hospital of Miami, surveyors weren’t just looking for compliance with specific standards; they wanted to see evidence of an overall culture of performance improvement and patient safety, says Faith D. Solkoff, RN, BSN, MPA, director of performance improvement.
"We drilled this new way of looking at the world — that it’s about getting ready for the next patient, not the Joint Commission — down to our leaders, staff, and physicians through many forums," she says. "As a result of our survey strategies, we received only a few minor recommendations, when other hospitals our size were getting conditional recommendations or very close to it."
Hard work paid off with positive feedback from the survey team, such as the nurse surveyor saying that she was hard-pressed to offer suggestions for improvement. "She said, In this case, there’s not a lot more that I can share that you all are not already doing. The truth is, I can take things I’ve picked up here to share with others," Solkoff notes.
For example, the nurse surveyor was impressed that no "Do-Not-Use" abbreviations were found. This was due to a combination of education, tools, frequent monitoring at the point of care and during twice weekly tracers, and addition of the Do-Not-Use list to medication order forms.
Surveyors were impressed with the hospital’s pediatric pain management educational tools, she reports. The nurse surveyor called the pediatric pain program "innovative, far above most top-caliber hospitals," and complimented the "Comfort Care" program. The program uses distraction techniques, use of EMLA cream, a staff-developed "Comfort Zone" evidence-based newsletter, and a dedicated pain team that reviews best practices and improvements over time.
Here are some of the effective survey preparation strategies used at Baptist Hospital:
- A continuous survey readiness team was developed to ensure compliance with standards and oversight of readiness activities, composed of team leaders representing JCAHO functions and priority focus areas.
- An Employee Guide for Patient Safety was distributed to all staff and physicians, to highlight all critical policies in a Q&A format. "We chose to keep JCAHO out of the title, as a way to remind staff that we incorporate standards into our policies to care for patients safely — we do not do this for JCAHO but for our patients because it’s the right thing to do," Solkoff points out.
- Frequent patient tracers are held, both on a unit- and hospitalwide basis. "We have two teams do tracers on a calendar basis, and we taught managers and directors to do their own," she says. "Quality management nurses are assigned to all units to assist with open chart reviews, safety rounds, and review of Q&As with staff. I facilitated mock system tracers for credentialing, human resources, data, and infection control."
- Frequent safety rounds are held. A team rounds three times per week with the involvement of the vice presidents, and a tool was developed for ongoing monitoring of compliance by managers and directors.
- A "Code Smart Plan" was developed. "This allowed us to get the word out quickly that the surveyors were in-house, and outlined a last-minute checklist for staff," Solkoff adds.
The plan outlines what leaders should do when they hear the "Code Smart" announcement via overhead page and by pager or phone call, alerting them that a surveyor or inspector is in-house. Staff use a checklist to make sure that "housekeeping" is done before surveyors arrive at their units, such as checking refrigerator temperatures and ensuring no clutter is visible.
"In retrospect, I wouldn’t do anything differently," Solkoff explains. "The surveyors commented that they found it hard to believe that the survey was unannounced, as we were so organized and the staff were so at ease. It is a credit to our hospital and medical staff leadership, as well as our staff, that we did so well. They are committed to excellence in patient care and safety, and it showed."
Patient flow
While the surveyors were polite and made the staff feel at ease, they were extremely thorough and went through the records with a fine-tooth comb, Solkoff explains.
"For patient tracers, some records were picked right from a schedule or census, others were chosen based on diagnosis/procedure, and other times they asked a manager to pick a patient who had moderate sedation, was do-not-resuscitate, or was in restraints," she says.
In obstetrics, the administrator surveyor was very specific and asked for a postpartum case of
a male infant born by cesarean on a Sunday, in order to assess security, teaching, and pain management, says Solkoff.
Patient flow was a major emphasis, and this standard came up at the introductory conference, during tracers of various units, and at the leadership session.
"They wanted to see that we had a plan in place to decompress the ED, and that these standards were applied to all areas of the hospital, not just the ED," Solkoff adds. "They wanted to hear about data for turnaround times of tests and procedures. On the units, they asked staff about flow — do you have the beds you need, and what happens if there is no bed?"
Beginning in January, a life safety code specialist joined the Joint Commission survey team during on-site surveys of hospitals with 200 or more beds. The specialist joins the team for a one-day review of life safety code and environment of care issues.
"This was our first experience with a life safety engineer. There was an intense focus on this — the engineer went top to bottom," she says. "You must be able to demonstrate compliance to all standards. The surveyor touched on every function and nearly every standard," Solkoff notes.
Questions posed
The life safety surveyor asked staff about evacuation in the case of a fire and fire emergency response. Other questions posed to nursing staff included "Who can shut off an oxygen valve?" and "What is your role in the event of a code red?" A housekeeper was asked, "What are material safety data sheets and where would you locate these?" and an engineering staff member was asked to demonstrate the process used to test fire pumps.
In prior surveys, the administrator really did not have the knowledge base to look at a building structure the way an engineer does, similar to the assessment done during state inspections, says Solkoff. "Now with the addition of the life safety engineer, they can," she adds. "If hospitals just treat this part of the survey like they would a state inspection, they’ll be fine."
The key to a successful unannounced survey is planning and incorporating the standards into daily patient care, says Solkoff. "The physician surveyor stated I would choose your hospital for myself and for my family.’ It doesn’t get any better than that."
[For more information, contact:
- Faith D. Solkoff, RN, BSN, MPA, Director, Performance Improvement, Baptist Hospital of Miami, Quality Management Department, 8900 N. Kendall Drive, Miami, FL 33176. Phone: (786) 596-2685. Fax: (786) 596-5983. E-mail: [email protected].]
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