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TOPIC: It all comes back to patient safety in Texas survey

HIM Connection, December 3, 2003

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"If you stood back on top of the building and looked down at everything that was going on during the survey, everything led back to patient safety," says Bob Tippens, MS, RHIT, director of quality improvement at East Texas Medical Center in Tyler.

During the facility's July survey, abbreviations, specifically unapproved abbreviations, were a hot spot, he reports. "If they're unapproved, it's a patient safety issue."

The medical center did not receive any IM-related Type I or supplemental recommendations. Tippens attributes the success in that area to the facility's point-of-care medical record review, which was implemented about five years ago. The surveyors looked at approximately 20 closed records, and the majority were open records on the units.

"They wanted to see whether everything was being documented in a timely manner and they found everything to be great. Point-of-care medical record reviews [helped] because everybody was used to everything being right on the unit; not getting some report out of the HIM department days later that says this or that wasn't done."

The surveyors also made it clear that they did not want directors and vice presidents on the hospital units when they were talking to the staff, Tippens says. "That's something else that's very important. We had our staff on the units well educated so they knew they were going to be on their own should a surveyor come up and talk to them."

The surveyors also looked in the records for collaboration among members of the health care team in designating the treatment plan.

The only surprise for Tippens was a patient safety and medication use interview.

"None of the reference books said anything about this particular interview because it was brand new for this year," he says. When he couldn't find any information on the JCAHO Web site, and only found one sheet about it in the survey packet, he called for background information. The JCAHO suggested he call the physician surveyor. After discussing the information on the sheet, Tippens said his impression was that it all relates back to the National Patient Safety Goals. "The surveyor said, 'You're exactly right.' So I pulled together a group of people who I thought were the best to answer those questions."

Another safety-related issue the surveyors asked about was whether the facility surveyed patients on their perception of their safety in the hospital. "We weren't doing that. As a result, we're going to include that question on our patient satisfaction survey that we send to every patient discharged from the hospital. That will be in effect before we become eligible for the unannounced surveys."

Overall, Tippens felt the surveyors were very fair and very educational. "They gave us some pointers of things that we probably should be doing, but they weren't things that caused a supplemental."

This week's HIM Connection was adapted from the special report, "Survive your JCAHO survey! Reports and advice from HIM managers in the field."

Click here for more information or to order. Also see the surprising results of a survey on preparation, view a chart review process flow chart, learn strategies for abbreviations and legibility issues, read how untimely telephone orders led to a Type I at MA facility, and much more.

Check out the Editor's Choice section below for solutions to your records completion problems.

Sincerely,

Kate Alvarez Editorial Assistant
kalvarez@hcpro.com

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