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JCAHO surveyors focused on verbal orders, equipment

Accreditation Connection, March 15, 2004

Documentation came under the microscope during two recent surveys by the JCAHO.

At one hospital, surveyors wanted staff to document any problems that they had with medical equipment. At another, they examined how well the hospital complies with its own policy to document all read-backs of verbal orders and critical test results.

Wayne Memorial Hospital in Honesdale, PA, scored a 98 during its November 2003 survey-and received compliments from surveyors for its high score.

However, surveyors also said the 92-bed hospital needed to keep better tabs on how well staff understand the medical equipment they work with.

Specifically, the surveyors want the hospital to document any user errors or near-misses that staff have with equipment such as cardiac monitors or patient-controlled analgesia (PCA) pumps.

"They want us to keep track of it so that we can pick up on trends with certain pieces of equipment, such as whether it's always the same equipment, person, or nursing unit that has problems," says Cinda Tietjen, RN, BSN, the hospitals' performance improvement manager and JCAHO coordinator.

The surveyors also suggested that unit managers identify staff who need extra training on certain pieces of equipment and to make sure they receive it.

Solution: Surveyors suggested that department managers review the medical equipment on their respective units each year with a biomedical staffer to determine whether staff require additional education.

Reminder: It's important that nurses and other staff understand how to use PCA infusion pumps, since JCAHO's National Patient Safety Goal #5 requires them to ensure that all general-use and PCA pumps have free-flow protection.

In addition, Goal #6 requires hospitals to perform routine preventive maintenance and testing on all clinical alarms.

Pella (IA) Regional Health Center wanted to go above and beyond the read-back requirement of JCAHO's second National Patient Safety Goal, which requires organizations to develop a process for verifying orders or critical test results that are received verbally/over the telephone.

Although the goal doesn't require hospitals to document the read-back verification, the rural hospital decided to write this requirement directly into its policies and procedures.

Problem: Staff did not consistently document their read-back verification. In addition, the hospital could only demonstrate six months of documentation compliance with the goal; surveyors during the November 2003 survey wanted to see a 12-month track record, says Barb Braafhart, RN, risk manager and privacy officer.

Solution: Unit nurse managers audit 10% of their orders each month. If 90% of them do not include a quick notation indicating who verified the verbal order or test result, the manager must provide education for all unit staff.

In addition, the manager must intensify the monthly audit by examining 50% of all orders. This continues each month until 90% of the orders include documentation of read-back verification, Braafhart says.

Most units already have a 90%-95% compliance rate. Problem units with lower compliance rates include the hospital's outpatient clinic, which is well below the target rate, says Braafhart.

"They're not used to doing this kind of documentation," she says. "Their volume of verbal orders is huge and to always remember to write down [the verbal order read-back] is difficult."

Solution: More education for clinic staff and monthly chart audits to assess their compliance.

The JCAHO will consider Pella to be in compliance with the goal once it can demonstrate 12 months of documentation of the verbal read-back, she adds.

Competency assessments: Surveyors were pleased with Wayne Memorial's competency assessments. In fact, surveyors told staffers they were doing more than they needed to, says Tietjen. Typically, department managers review all competencies for each staff position on their units each year.

The surveyors said this was overkill. "They told us that we could do less and gave us good suggestions on how to refine that process by reassessing certain competencies more often than others," she says. Surveyors did not say which competencies should be reviewed most often, however.

"They left it up to us, so we'll be reviewing it," she says.

Surgical site marking: Pella received a Type I finding for using stickers to mark surgical sites. National Patient Safety Goal #4b requires hospitals to develop a process for marking the surgical site.

Note: Beginning January 1, the JCAHO retired its "Type I" designation in favor of the term "noncompliant."

Although the JCAHO has advised hospitals to use an indelible marker to mark the operable site, Pella asked the JCAHO for permission to use stickers instead.

However, the JCAHO responded with a resounding "no." Pella received the response just three weeks before its survey, however, allowing surgeons little time to comply.

Problem: Surgeons and staff preferred the stickers because they didn't want to risk leaving a permanent mark on a patient's skin. They were also concerned that a marker could cause the site to become infected.

The sticker system worked well, they argued. In fact, Pella has never had an adverse event or a near-miss due to using stickers to mark the surgical site.

That didn't impress the JCAHO, however. "The JCAHO said it didn't like the sticker system because it isn't foolproof. Stickers don't stay on the site, and you have to remove the sticker to scrub the surgical site," Braafhart says. This leaves open the possibility that the sticker will be placed back onto the wrong site, the JCAHO reasons.

In fact, a statement released by the JCAHO in 2003 notes a lack of scientific evidence to suggest an increased risk of wound infection caused by using a marker on the surgical site.

"Special surgical marking pens that will not be washed off by the surgical prep are available," the JCAHO pointed out.

Solution: The chief nursing officer and the director of surgery met with surgeons to explain why they must mark the site with an indelible marker.

This tactic yielded significant results, as the operating room director who monitors surgeons' adherence to the JCAHO's site-marking requirements has reported a 100% compliance rate, says Braafhart.

National Patient Safety Goals: Surveyors were pleased with the notebook that Wayne Memorial uses to track its compliance with the Patient Safety Goals.

The hospital's performance improvement coordinator and safety officer keep a notebook with tabbed sections for each of the seven Patient Safety Goals.

Within each section are narratives, policies, and forms to show how the hospital complies with each goal and who is responsible for taking action.

The facility has a similar notebook to demonstrate its response to the JCAHO's Sentinel Event Alerts.

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