• E-mail
• Print
• RSS

The JCAHO's new survey process: Questions that all staff should be ready to answer

Nurse Leader Weekly, May 4, 2004

Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Weekly!

The Hospital of Saint Raphael in New Haven, CT, is a 511-bed academic health-science center affiliated with Yale University School of Medicine. It treats more than 24,000 inpatients and 123,000 outpatients annually in its emergency department, ambulatory/surgical departments, and outpatient clinics. Seven JCAHO surveyors spent four days at the facility in February.

Surveyor questions that all staff should be ready to answer

The following is a sample of questions JCAHO surveyors asked staff during the Hospital of Saint Raphael's February four-day survey:

Medication tracers

• What do you do to improve safety?
• Have you done a Failure Modes and Effects Analysis (FMEA) on medications?

(Note: The hospital did do an FMEA on chemotherapy. The director of pharmacy explained the process and outcome, but the surveyor did not ask to see documentation.)

• What do you do when you receive a verbal order?
• Are respiratory-therapy orders reviewed before a therapist administers the first dose?
• How do staff learn about new drugs?
• What is your process for reporting drug errors?
• Who addresses drug errors?

National Patient Safety Goals

• What is your policy on time-outs?
• Where is your documentation?

(Note: Surveyors looked for documentation of time-outs in all records reviewed to ensure that it was recorded either by hand or electronically.)

• Which abbreviations does your organization prohibit?

General patient-safety issues

• Do you have a safety program?
• What has the hospital done to improve safety?
• How have leaders supported quality improvement and patient safety?
• How do you involve house staff and residents in quality improvement and patient safety?
• How do you identify issues?
• How do you prioritize issues?
• What have you done to improve the medication process?
• Do you have an interdisciplinary approach to patient-care delivery?
• How do you document this process?

- Adapted from Briefings on JCAHO, HCPro, Inc., April 2004

Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Weekly!

• E-mail to a Colleague
• Print
• RSS
• Archive