Are you ready for Tracer Methodology and the JCAHO's Periodic Performance Review? Keeping up with the JCAHO s sweeping accreditation changes has never been more important OR difficult Briefings on JCAHO is the 12 page monthly resource that over 80 percent of ALL accredited hospitals turn to for each month to provide them with the how to strategies and tools that they need to remain in compliance with the JCAHO s requirements
April 2008 (Volume 19, Issue 4)
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Surveyors praise emergency management plan During the facility's 2007 Joint Commission survey, Memorial Health University Medical Center, Inc., in Savannah, GA, received high praise from a physician/administrator surveyor regarding its emergency management plan. Specifically, the surveyor said that the facility's emergency management plan should be the model for the nation. IV drugs in the emergency department Identify how Joint Commission standards address mixing IV medications Revamped nursing documentation increases patient care, improves Provision of Care When Gwinnett Medical Center in Lawrenceville, GA, decided to cut nursing paperwork by 50% to increase nursing time at the bedside as well as accreditation survey results, it was an all-hands-on-deck approach.
"Even though our customer service scores were not down, we looked at clinical indicator surveys," says Deborah Briese, RN, BSN, CCRN-CMC, who is in charge of Provision of Care chapters for the facility. "What we found was that it was the paperwork that was keeping us from patient care." MD hospital avoids hand hygiene RFI, finds areas for improvement Multiple mock surveys prove to be one of the best ways to prepare staff members and hospital systems for unannounced Joint Commission surveys.
Mary Williams, RN, Joint Commission (formerly JCAHO) regulatory coordinator at Peninsula Regional Medical Center in Salisbury, MD, orchestrated three mock surveys before the unannounced survey in December 2007.
The 375-bed hospital, located 29 miles from Ocean City, MD, created a J-code to notify medical staff, managers, and supervisors when the survey or mock survey was taking place. How to find methods to assess continual survey readiness in your facility Finding a way to evaluate hospitals in preparation for the next unannounced survey can be a frustrating task. Proper use of PPRs and employee encouragement programs are two ways successful hospitals equip staff members to maintain survey readiness, and they are seeing results. Using a PPR program is a good way to get organized and shift staff perspective from preparing for a survey to a culture of continual compliance, Jodi Eisenberg, MHA, CPMSM, CPHQ, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago, said during HCPro's February 5 audioconference, "Survey Readiness: Strategies, Tools and Tips for Joint Compliance." Looking to the standards to address flash sterilization Editor's note: This feature explores problematic Joint Commission standards with expert advice from BOJ advisors. This month, Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, a healthcare consultant in Trabuco Canyon, CA, discusses challenges surrounding medication management and black box labels. When looking at a facility's use of flash sterilization, any number of standards could apply. The appropriate standard to consult is entirely situational. Infection control would be at the forefront-IC.2.10, IC.3.10, IC.4.10, and IC.5.10 would all have some bearing on the process-but Leadership standards are also important in this situation. A look at postanesthesia evaluations as related to CMS guidelines In a recent CMS Corner, we discussed federal regulations published in the Federal Register that were effective for history and physical (H&P) exams, verbal orders, security of medications, and postanesthesia evaluations as of January 2007. Subsequent changes effective January 2008 were published for H&Ps and postanesthesia evaluations.
