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Learn how to tackle problematic standard (IM.6.30)

Accreditation Connection, August 6, 2004

Simplify your policy. According to Bud Pate, REHS, practice director for clinical operations improvement for The Greeley Company, a division of Marblehead, MA-based HCPro, Inc. your policies should specify what constitutes an invasive procedure (which procedures in your institution place the patient at risk for injury or death) and the scope and content of the history and physical (H&P) for the various invasive procedures defined.
Allow physicians the flexibility to focus their H&Ps based on the condition of the patient and the risk of the procedure. However, remember that with flexibility comes the responsibility for review. Make sure the medical staff is reviewing and improving, if necessary, the scope of the H&Ps done for procedures outside the operating room (OR).

Elect a gatekeeper. Carry out a system whereby the floor staff cannot release the inpatient for surgery, and the pre-op holding staff cannot release their patients to the OR without a complete H&P, says Glenn D. Krasker, MHSA, president of Critical Management Solutions, a consulting firm that specializes in medical error risk reduction in Wilmington, DE. He notes that this approach requires solid backing from senior management and medical staff leadership because the frontline staff are putting their necks on the line by holding patients.

Get the process formally signed off by the chief executive officer and chief of staff before establishing and educating the medical staff on the new process as well as auditing and backing up those gatekeepers. If properly put into place, it will make a poorly scored standard in this area virtually impossible.

Elect a gatekeeper in the recovery room, too, says a source close to the JCAHO. Complete a postoperative note according to the JCAHO's requirements.

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