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See how JCAHO surveyors checked out one hospital's compliance with its National Patient Safety Goal policies

Nurse Leader Weekly, June 28, 2003

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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2003 National Patient Safety Goals were at the forefront of JCAHO surveyors' minds when they visited one California hospital in late January 2003.

Not only did they grill attendees at the patient safety/medication management interview on the 11 new recommendations, they also brought up the goals in the leadership and performance improvement interview, says Ann Kapernick, RN, BSN, CPHQ. She is the administrator of quality and risk management and co-leader of one of the three committees in charge of patient safety at Ridgecrest Regional Hospital in Ridgecrest, CA.

Surveyors wanted the anesthetist, an operating room nurse, a surgeon, and the patient to be involved in the conversation about the surgical site before the patient was anesthetized. They also wanted staff to document the time out. Here's what else surveyors focused on:

1. Medication management

"That was just huge," says Kapernick. She got the feeling that surveyors were testing out the "tracer methodology" on tap for next year, in which they will follow individual patients throughout their stay. At Ridgecrest, surveyors followed a patient or two, not only checking up on the medications they received along the way, but examining staffing competencies for the people who took care of that patient.

"They were really happy with our Medication Collaborative Safety Team," says Kapernick. Surveyors want to see a designated team for addressing medication safety problems-that's in addition to any general patient safety team you might have.

TIP: Establish a central committee, such as a quality council, and have your medication and other safety-related teams report to it.

2. Human resource (HR) staffing standards

Surveyors paid particular attention to these standards, which require hospitals to examine staffing levels coupled with clinical goals. "We were able to at least show that we had six months' documentation on two projects and we were able to show the data connected thus far," says Kapernick.

Summing up the experience, Kapernick says surveyors basically wanted to make sure that all the policies you've implemented are working. "That they're functioning, not just policy."

Adapted from: Briefings on Patient Safety, www.hcmarketplace.com/Prod.cfm?id=234&S=ENMW.

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