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Currents At the Aug. 22 communications meeting Kathy Wade, JCAHO consultant, gave a summary of “Tips for Success” with the JCAHO survey process. We are expecting the week-long survey to be conducted in October and we are awaiting word on the specific date at this time. A summary of Ms. Wade’s presentation is highlighted below. The survey process is exhaustive. Everyone has a role to play in demonstrating quality care and service. We have been advised that the survey process involves greater interaction with employees than in previous years. Now is the time to fine-tune our knowledge and get fully prepared for the survey. Everyone’s attention and full cooperation is needed.  Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center JCAHO Survey Process 2000—Tips for Success Visit to Patient Care Setting Discussion about volume and scope of services provided; Tour of area/general care observations; Multidisciplinary care provider meeting; Medical record review; Conversation with patients Observations/Conversation with Patients by Surveyor Procedures and treatments administered according to policy; Patient’s experience during the admission process; Types of education received by the patient; Information given to the patient/family regarding discharge planning; How patients voice a complaint (see MUSC Medical Center Policy No. C-9, Customer Satisfaction Policy) Tour of Patient Care Setting  Appropriate equipment (including crash carts) is available and inspected according to policy; Reference material is accessible to staff (policies and procedures, MSDS, and so forth); Evidence of educational opportunities for staff (displayed on bulletin boards and through other documentation); PI project storyboards, displays, etc.; Areas provide for patient privacy, security and confidentiality; Space is appropriate for services and meets Life Safety Code requirements; Clean supplies and equipment separate from dirty; Refrigerator logs up-to-date; Medications are secured; Food and nutrition products stored appropriately Multidisciplinary Care Provider Meeting: Questions How are patients involved in care? Consent process; Advance directives; Care decisions consider patient/family preferences; Resolution of ethical dilemmas; Informed of patient rights and responsibilities; Patient education process; (See MUSC Medical Center Policy No. C-1, Patient Rights and Responsibilities, and related policies) Group Questions How are staff competencies evaluated? Hiring process screening; Central/department orientation; Ongoing in-service and competency training; Mandatory annual review of information with post test; Performance standards are established through the position description/performance evaluations document evaluated on an annual basis; Annual competency report to the Board; (See Medical University Hospital Authority Policy No. 5, Competency Assessment) How is patient confidentiality maintained? No clinical information displayed in public areas; No discussion of patient cases in public; Secure fax and e-mail of information; Password protected electronic data; Consent for release of information; Limited access to patient information based on job; Compliance program for reporting potential issues; (See MUSC Medical Center Policy No. C-3, Patient Confidentiality, and related policies) How are staffing levels adjusted based on patient need? Consider patient acuity levels, type of care provided, technology used; Staffing resources include hospital pool of staff, contract agencies, staff overtime; Staffing variance reports provide information for monitoring staffing and planning future needs How is care coordinated among health professionals and services? Consultations; Patient care rounds; Patient care conferences; Manual and electronic medical record; Documentation found in the inpatient databases, pathways, patient education flow sheet, consult reports, or progress notes How have clinical practice guidelines been considered in design or improvement of clinical processes? Protocols, algorithms, and pathways are developed using national practice guidelines, professional standards of care and best practice evidence; Priorities based on high volume, high risk, problem-prone processes in patient populations; Pathways are monitored through variance tracking; Data from variance tracking is used for performance improvement What initiatives have been implemented to improve performance? Organizationwide: ID Band, Discharge Process, Electronic Medical Record, Medication Process, Blood-Borne Pathogen Treatment Time, others . . .  Department-specific: Ventilator, C-Section, Patient Satisfaction (Ambulatory areas), IOP Medical Record, others . . .  What is the sentinel event process? Occurrence report/initial investigation (Risk Management); Determination that occurrence is a sentinel event using JCAHO definition; If sentinel event, a multidisciplinary PI team is formed to conduct a root cause analysis and action plan; Root cause analysis and action plan reported to Quality Council for approval; Implementation of risk reduction strategies with Quality Council oversight; (See MUSC Medical Center Policy No. C-49, Sentinel Events) Medical Record Review Be prepared for surveyors to ask for medical records of patients receiving procedures such as conscious sedation, surgery, restraints, etc.; Continue ongoing review of open records for completeness in documentation; PI initiatives regarding medical record documentation based on data from closed record audits, concurrent record audits, procedure reviews and other special projects Medical Record Review: Hot Topics All entries dated, timed, signed and authenticated as necessary (minimum of history and physicals, operative procedures, consultations, and discharge summaries are authenticated); Operative reports dictated or written immediately after surgery; Verbal order signatures within 48 hours (except for restraints—24 hours); History and physical, nursing assessment and screening assessments within 24 hours; Advance directives; Informed consent, assessment and monitoring for procedures; Interdisciplinary care plans; Time-limited restraints orders; Discharge planning; Patient/family education; Appropriate referrals made to other disciplines and assessment completed in the record according to policy; Social work—24 hours; Physical Therapy— contact within 24 hours and evaluation initiated, completed within 48 hours; Occupational Therapy— contact within 24 hours and evaluation initiated, completed within 72 hours; Speech—24 hours; Dietitian (from admission date)—48 hours (ICU), 72 hours (database screen) Function Interviews Surveyor will address standards based on issues raised in the document review and other survey activities; Important to review JCAHO standards and MUSC policies and procedures relevant to the interview topic; Practice responses to the questions and give examples demonstrating compliance; Reference relevant data (financial, clinical, utilization) used in decision-making; All attendees must participate! Building Tour: Key Points Fire alarms functional; Staff knowledge regarding 5-Step Fire Plan—Remove patient, close door, pull alarm, call operator 792-3333, fight fire; Evidence that infection control policies and procedures have been implemented; Social environment appropriate for care and services; Address above-the-ceiling issues such as wall penetrations, smoke detectors, fire dampers; Physical environment free of hazards; Safe storage of supplies/equipment (oxygen cylinders, medication, etc.); Unobstructed access to exits; No evidence of smoking in undesignated areas  Changes to Payroll Process Melissa Forinash, Director, Center for Computing and Information Technology (CCIT), and Robyn Frampton, director of Fiscal Affairs, discussed the need to move the biweekly payday from Tuesday to Wednesday. This change is needed to enable extra time for payroll processing and therefore reduce the risk in “missing” a payroll. The target date for the change is Oct. 4. Information Management Survey Christine Lewis, manager, Coding and Record Processing, and Jeff Burdick, manager, Health care Administrative Systems (CCIT), discussed the JCAHO standard concerning information management. The JCAHO standards define four information management functions needed to improve patient outcomes and individual and hospital performance including: Patient Specific Data and Information; Expert Knowledge-Based Information; Aggregate Data; Comparative Data Currently a survey is underway to assess information management needs. Broad-based participation in the survey is encouraged. The survey will be issued through a broadcast e-mail message and website on or around Aug. 28.