SDS Accreditation Update: Improve patient safety with updated H&Ps, clean handoffs
SDS Accreditation Update
Improve patient safety with updated H&Ps, clean handoffs
Policies and staff education ensure consistency before the surveyors show up
Are your history and physicals (H&Ps) updated and documented within 24 hours of the procedure? Is communication clear when you are handing off patients from one area to another, such as from the OR to post-op? If not, and you work at a hospital or freestanding surgery center, you are violating requirements from the Joint Commission on Accreditation of Healthcare Organizations.
To ensure that surgeons are aware of any changes in their patient’s condition since the time that the H&P was performed, the hospital and ambulatory care standards require an update to the H&P within 24 hours of an invasive procedure, says Michael E. Alcenius, MS, PA, associate director of the Standards Interpretation Group for the Joint Commission.
While the standard does not apply to organizations surveyed under the requirements of office-based surgery centers, an update to any assessment performed prior to the day of a procedure is good practice, he suggests.
Although this standard was introduced in the Joint Commission standards in 2004, more organizations, even those not accredited by Joint Commission, are focusing on the requirement now that the Centers for Medicare & Medicaid Services now requires the H&P update, Alcenius says.
The Accreditation Association for Ambulatory Health Care (AAAHC) does not have a specific policy related to history and physical updates, according to an AAAHC spokesman.
"Most organizations are conducting the updates in some way, but they may not be documenting it clearly," he says. "The update to an H&P can be a written note on the original H&P that states no change,’ or it can be written in a progress note or marked on an anesthesia flow sheet. We are flexible in the type of documentation needed, but it does need to be documented."
While the Joint Commission accepts H&P updates from any practitioner allowed to conduct assessments within their scope of practice, such as surgeons, anesthesiologists, certified registered nurse anesthetists, advanced practice nurses, or physician assistants, the policy at Providence Newberg Hospital in Newburg, OR, requires the surgeon to document the update, even if the original H&P was performed by another physician, says Sarah L. Breckenridge, RN, BSN, CNOR, surgical services manager.
"Surgeons see the patient in the pre-op area to review the H&P, make sure there are no changes, and sign it," Breckenridge says. If there is no change, the surgeon writes "no change" at the bottom of the original H&P, but if there is a change, the surgeon indicates the change and dates it, she adds.
"There was some resistance when we first implemented the policy for the 24-hour update because many surgeons thought that the requirement was unnecessary," Breckenridge admits.
With administrative and medical staff leadership support, surgical staff members were able to meet the requirements for the update by refusing to move the patient from pre-op to the operating room, she says.
Once most surgeons began visiting pre-op to update the H&Ps, other surgeons began to do so with fewer complaints, she says.
"There was definitely peer pressure to follow the rules and stop complaining," she adds. "The medical staff director was also willing to talk with surgeons who did not want to comply."
While her facility does have a postoperative form that includes a space for a physician to mark that there is no change in the H&P, Breckenridge discourages the use of the form for this purpose.
"Now that Joint Commission uses the tracer methodology to follow a patient, the H&P update doesn’t appear to occur until after the patient is out of the operating room," she says. "We recommend making the note on the original H&P so the surveyor sees the note before the patient moves to the operating room."
Another way that Joint Commission is encouraging up-to-date communication is the 2006 National Patient Safety Goal that requires outpatient surgery programs to develop a standard process to ensure communication as a patient moves from one area of care to another.
Alcenius says, "A surveyor won’t be looking for specific types of documentation, but a surveyor will expect to hear employees describe a process to give information about a patient being moved to another area that is the same for all patients in all areas."
While the ideal form of communication is face-to-face, outpatient surgery programs may use a combination of verbal, recorded, or written communications, Alcenius continues.
A task force to address handoff communications has been established at Spartanburg (SC) Regional Hospital, but it has only just begun to take steps to address the issue, says Anne Stokes, RN, BSN, CPAN, manager of post-anesthesia care unit.
The department is looking at how to use existing computer systems to share information, but the concern is the requirement that the receiving staff member be able to ask questions, she says.
In larger hospital settings, recorded or written messages with information about patients being transferred to another area can create problems because they don’t always enable the receiving staff member to ask questions, Alcenius admits. If the message or written report includes the name of the person who cared for the patient and information on how to reach them for questions to clarify information, then the handoff communication is more acceptable than when no contact information given, he says.
"Freestanding same-day surgery programs will be able to meet requirements of this patient safety goal more easily because the staff [number] is smaller, the environment is smaller, and it’s much easier to communicate," Alcenius adds.
While the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF) does not have a standard that addresses handoff communication, the organization does provide guidelines that intraoperative and anesthesia personnel should follow as patient information is communicated to a receiving department, says James A. Yates, MD, a Camp Hill, PA, plastic surgeon and president of AAAASF.
"This is not a problem in most office-based surgery programs, but staff members need to know what to communicate, and they need to know how to ask questions to make sure the information is understood," he says.
"When the staff member receiving the patient is able to repeat back the information, you can be sure that information has been given correctly," Yates says.
Paying attention to handoff communications is important regardless of the size or type of outpatient surgery program in which you work, he says. "This is something that costs nothing to do correctly, and it is key to providing safe patient care," Yates adds.
Sources
For more information about history and physical updates or handoff communications, contact:
- Michael E. Alcenius, MS, PA, Associate Director of the Standards Interpretation Group, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5900.
- Sarah L. Breckenridge, RN, BSN, CNOR, Surgical Services Manager, Providence Newberg Hospital, 501 Villa Road, Newberg, OR 97132. Phone: (503) 537-1767. Fax: (503) 537-1819. E-mail: [email protected].
- Anne Stokes, RN, BSN, CPAN, Manager, Post-Anesthesia Care Unit, Spartanburg Regional Medical Center, 101 E. Wood St., Spartanburg, SC 29303. E-mail: [email protected].
- James A. Yates, MD, Plastic Surgery Center, 205 Grandview Ave., Corporate Place, Suite 401, Camp Hill, PA 17011-1714. Phone: (717) 763-7814. Fax: (717) 763-4918. E-mail: [email protected].
For more information about implementation expectations and frequently asked questions about hand-off communications and other National Patient Safety Goals, go to www.jcaho.org. Under the "Top Spots" section, choose "National Patient Safety Goals and FAQs."
For more information H&P update requirements, go to www.jcaho.org. Under the "Top Spots" section, choose "Standards FAQs — Ask a Question." Choose the manual under which your organization is accredited, then under "Provision of Care," scroll down to "history and physical." If an answer to your specific question is not listed, follow instructions to submit your question.
Are your history and physicals (H&Ps) updated and documented within 24 hours of the procedure? Is communication clear when you are handing off patients from one area to another, such as from the OR to post-op? If not, and you work at a hospital or freestanding surgery center, you are violating requirements from the Joint Commission on Accreditation of Healthcare Organizations.Subscribe Now for Access
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