Nursing

National Patient Safety Goals notebook helps DE hospital through its JCAHO survey

Nurse Leader Weekly, August 1, 2003

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Nanticoke Health Services in Seaford, DE, includes 110 acute care beds, a long-term care facility, wellness centers, and physician and rehabilitation clinics. Two surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a physician and a nurse, visited the organization in early April for five days.

Surveyors surprised Jeff Willey, MSN, MEd, RN, corporate performance improvement (PI) specialist at Nanticoke Health Services, by kicking off their visit with the document review rather than the performance improvement (PI) interview.

"Personally, I'd rather do [the PI interview] first, and get it over with, but it really wasn't bad," he says. "Actually, we got done 20 minutes early because they ran out of questions-which is the first time I have ever had that happen."

There, and throughout their entire visit, surveyors focused on the 2003 National Patient Safety Goals-particularly in the areas of patient identification (Goal 1) and the list of "do not use" abbreviations (Goal 2).

"Luckily, I had put a book together on what we had done to meet those goals," says Willey.

In a binder, he outlined all six goals in a grid-similar to the way many hospitals document actions taken after the JCAHO releases a Sentinel Event Alert-with the recommendation in the first column, the hospital's current practice in the second column, and how the hospital will change its policies and procedures to meet the recommendation in the third column.

The notebook also included all the documentation that illustrated how the hospital had met those goals, including items such as a

  • Failure Modes Effects and Criticality Analysis the hospital performed on patient identification
  • copy of the operating room's pre-procedure checklists
  • copy of the anesthesia record, which includes a new check-off box to indicate that clinicians identified the patient

Staff focused the PI presentation on the JCAHO's current hot issues, such as staffing effectiveness, the National Patient Safety Goals, Failure Modes and Effects Analyses, and root-cause analyses.

However, they discovered that some issues-such as the staffing effectiveness standards-might not have merited as much attention as staff had given them.

Tip: Use the time you devote to complying with the JCAHO's staffing effectiveness standards wisely. "We had spent an immense amount of time, and were told that we did too much," says Willey. In addition, surveyors explained that they preferred a format where all the indicators were on one page and were compared with one another in a multi-line graph. "Make sure you have your numerators and denominators specified," Willey warns.

Tip: Make sure your leaders memorize your facility's responses to the staffing effectiveness and National Patient Safety Goals. Surveyors quizzed Nanticoke's leaders on both those topics during the leadership interview.

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



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