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'Everyone' involved in Joint Commission readiness
Preparation for Joint Commission surveys and measuring performance improvement at St. Vincent's HealthCare in Jacksonville, FL, involves all staff. And it seems to be a method that works. The hospital was just recognized for the fifth consecutive year as a Distinguished Hospital for Clinical Excellence by HealthGrades.
As part of the "chapter champions" team at St. Vincent's, one person is assigned to be the lead of each chapter of The Joint Commission's accreditation manual. Under each team leader are team members with specific tasks. The team meets on a weekly or biweekly basis to study all the regulations and all the elements of performance to understand how to measure them, how to abstract the data, how to do audits, and then how to identify weaknesses and strengths from those audits.
A weekly memo goes to every nursing unit and all nursing personnel on Joint Commission readiness or whenever a change or a new policy is introduced. Staff are required to sign off as verification they have read and understood the memo.
Readiness at the hospital involves constant reinforcement and education, as well as having accountable leaders, says Phil Perry, MD, MBA, chief medical officer. "The team leader on the skin ulcer bundle can't visit 400 patients a day to see if they're being turned and if their bed surface is proper and that they're getting good nutrition. It doesn't work that way. Each caregiver has to be responsible for that," he says.
Data on standard measures such as falls, skin ulcers, and DVT prophylaxis are posted in nursing break rooms, in the hallways, and in doctors' lounges so that physicians, nurses, and patients can see how the hospital is measuring up. "It helps people understand what we're measuring and what their performance is. People are naturally competitive. They don't come to work wanting to do something poorly, so when they know they are being compared to their peers, they tend to have a healthy competition," Perry says.
St. Vincent's was surveyed Nov. 15, and Perry says surveyors focused heavily on the National Patient Safety Goals. There also was a "big emphasis" on patient safety in terms of anesthesia, sedation, and the process of medication safety. "Medication management is a big deal; medication reconciliation is still a trouble spot for most hospitals because it's very difficult to do it completely and satisfy what The Joint Commission is requiring," Perry says.
The reconciliation process might look easy on paper, he says, but "it's very hard to do in the real world, particularly getting medication lists to the patient and to the patient's next provider after discharge." But, he says, St. Vincent's is doing "pretty well" on it, and having electronic medical records has helped that along. Getting a complete list at admission is difficult and an "imperfect science," but if you can capture a complete list in an electronic medical record, "you're much more likely to have that same proper list on discharge."
Perry says the 513-bed hospital did a good job on the life safety portion of the survey. "The key," he says, "is that you have to survey yourself ahead of time." If your hospital is new, you must identify deficiencies and start forming a plan to bring it up to speed, for instance with fire safety codes or if you're in a hurricane-risk area shutters on all of your windows.
"Making sure people are trained to do what they're doing is important, too," Perry says. "Showing that people have had adequate education and reeducation, reorientation, and updated credential files — those things were looked at in a lot of depth."
Overall, "we got a lot of positive feedback," Perry says. "One thing was the organization was well prepared and enthusiastic about getting the survey. We were ready to get surveyed." He says the med-surg unit had worked hard to prepare for the survey, and when the last morning of the survey came and the unit had not yet been visited, staff asked surveyors to visit the unit and volunteered to have a tracer. "That just shows you that people were ready and confident," he says.
His advice to QI directors: "I think that having a commitment from the leadership, both from the medical staff leadership and the nursing leadership, with the support of your operations (the COO and CEO)" is important. "The board of directors have to be committed to it as well. The board has to set the tone that it's an expectation — not a request, but an expectation, a requirement — that patients are treated as safely as possible. When that happens at the top, people are empowered at the bedside to find ways to make it happen."
Another important element to readiness is when you see a problem, to make a rapid cycle change and to educate staff on it, he says.
HA pressure ulcer rate = 1 per 1,000 patient days
One area the hospital received kudos from The Joint Commission on was its work on pressure ulcers. "I think they were very impressed, particularly the nurse surveyor because she spent the most time going over it, with the consistency on patient assessment, particularly with skin bundles," Perry says.
St. Vincent's, as part of Ascension Health, was selected in 2004 as an alpha site to work on decreasing hospital-acquired skin ulcers, a still-significant problem nationwide. In creating a bundle that worked for the hospital, "we identified things like bed surfaces and different types of sheet covers and different types of pads that can raise or lower skin ulcer rates." It was a detailed process, but in doing that they found that one type of bed pad, which was thought to be more economical, was actually leading to skin redness and irritation. "You really have to be vigilant about your data collection and analysis when your data have changed for better or worse," Perry says.
All patients, he says, should be viewed as at risk for pressure ulcers. For example, patients who have had prolonged neurosurgical procedures "can get skin breakdown from the pressure on the forehead or the pressure on the shoulders or knees. So you have to take extra precaution to make sure that sheets are gathered up, that you have padding at all the pressure points," he says. And to act when the patient is able to be lifted to allow for recirculation.
Accountability also has played a role in the hospital achieving its current rate of one case of hospital-acquired pressure ulcers per 1,000 patient days. For each NPSG, core measure, or other significant quality measure, St. Vincent's HealthCare appoints a nurse as a lead. He or she reports to the chief nursing officer, Karen Darnell, RN, MBA, "who has a very active engagement in expectations of accountability," Perry says. The leaders meet on a regular basis to discuss successes and failures. "You want to celebrate your successes, but you want to examine your failures," he says.
The leaders make rounds, and when they identify a patient with a skin breakdown, they look to see what was done properly using the SKIN bundle:
Those leaders, in turn, provide feedback to the nurses caring for the patients on what was done well and what was not done that should have been done. "That feedback is very important," Perry says. "You want to add more positive feedback than negative or you discourage people from succeeding. But you've got to have ongoing analysis."
Door-to-balloon time decrease
Another area St. Vincent's has had success is in lowering door-to-balloon time. Perry says they first realized the time was too long so they gathered personnel, including ED physicians and nurses and cath lab cardiologists and nurses, together to examine each data element of the process and patient flow. By breaking down each step and recording the data, "we could identify which steps seemed to be the constraint in getting the patient into the cath lab and a balloon into the distressed artery in 90 minutes or less."
Looking at individual cases, the team started eliminating barriers. The team realized that if they added a stopwatch to the patient "with an expectation that we want you to the cath lab within 90 minutes, everyone could see the watch as a reminder that time is critical." By getting members on board collaborating and then educating staff on the findings, they started to see door-to-balloon time decrease, Perry says. Once they started seeing successes, they looked to see what made that case quicker. "Then you look at those same data elements and say we eliminated 10 minutes here, six minutes here, eight minutes there and ask what did we do different this time." Now their numbers are, on average, below nine minutes.
"We know that it can be done and it's possible. One of the things that was very helpful as positive reinforcement for the emergency room staff and physicians was to take still pictures of the fluoroscopy that's done during the procedure and show the before and after of the actual arteries.... That kind of positive reinforcement really gets people excited."