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Wayne Memorial Hospital in Goldsboro, NC, was surveyed Jan. 26-30, 2009. But the 316-bed hospital, prepares for its survey just about every other day of the year.
Debbie M. Phillips, MPH, RN, ONC, director, accreditation and regulatory/patient safety officer, says a regulatory committee meets monthly. Each "chapter leader" reports on progress associated with his or her area. Phillips also performs two tracers every month. Directors, educators, and rotating staff personnel participate, and Phillips reports her findings at performance improvement meetings attended by all department directors and administrative staff, who take the information gleaned back to their staff.
Phillips publishes a monthly newsletter based on reading she has done of compliance publications. She highlights "hot spots" and posts the newsletter on the hospital's intranet. She also posts a multiple-choice "question of the month" to test regulatory knowledge. Rationale for the correct answer is provided.
In 2008, Wayne Memorial hosted a quarterly "Joint Commission Fair," with booths based on different chapters of The Joint Commission manual. At the end, staff take a clinical and a non-clinical test.
Tracer results also are posted online so staff can see what other staff are doing. "You find the same things sometimes for multiple units, so if something has worked for one unit then maybe they'll share that with other units," she says. She tries to limit tracers to one hour. They are good practice for staff to ready themselves for the surveyors' tracers. "I tell them, 'I'm friendly fire,'" she says. "And I do think they help with staff communication with surveyors; it takes away that fear factor by doing this. And then when I report all of this, I report the areas that need improving. I also report the things they're doing well. And I give kudos to individual staff members as well."
Every two weeks, she speaks at the hospital orientation on patient rights and safety in which she presents some Joint Commission and other regulatory information. Twice a year, the hospital hosts a new manager orientation during which Phillips gives an hour talk on regulatory information.
Scoring changes process
Referring to changes in 2009 Joint Commission standards, "the scoring in itself makes the standards change because every standard now is labeled direct impact or indirect and based on the criticality," Phillips says. "That in itself, although the verbiage of the standards hasn't changed, the fact that they are scored that way, to me, much more impacts your ability to be accredited because, based on your bandwidth or based on the hospital beds and your survey days and the width of which you are given so many direct impact requirements for improvement [RFIs], that's how you determine your accreditation status. The fact that the standards are divided [that way], you can shut the doors of the organization if you don't wash your hands, for example."
Now, she says, a hospital can have multiple supplemental findings so "an organization can have several of those and not meet the standard, but where your accreditation lies and based on what I've understood, it's the number of direct impact standards that you are not compliant with," she says.
"And so when you look at it, say an organization has six direct impact standards that they don't meet but they can have 20 indirect that they don't meet. You used to look at that and say I have 26 RFIs, but now the focus is really on that direct impact. Once you look at that, then you can kind of see where the focus is, where the emphasis is."
Two surveyors were at the hospital for five days, and a life safety code specialist visited on day two.
So where would she tell hospitals to focus now in preparation for their surveys? "If I would say focus on anything, I would say look at those NPSGs [National Patient Safety Goals]. There wasn't a tracer any day, any event that went by where what was done wasn't related to those NPSGs. Those are critical.
"And this to me was one of the more intense surveys I've ever participated in. I've been a nurse for 32 years. The gray is gone. It's black or it's white. So that takes away a lot of the surveyor bias, although I still think that's possible and noted," she says.
The surveyors also focused on the Universal Protocol and the added elements to the time out. "They watched time outs everywhere — in the OR, interventional radiology, to see that you were doing them the same and what your focus was. And it shouldn't just be a checklist that you're checking off. The staff performing the time out need to associate that time out with the rationale for why they're doing it," Phillips says.
The hospital was applauded on how it maintained the integrity of crash carts. "They like the fact that we had turned ours around so that the average public couldn't look and see what this cart was. They liked that a lot. That promoted safety as well as promoting the integrity of the cart. So the next time it's used, you would know that what you needed was there," she says.
Surveyors also praised the follow up Wayne Memorial was doing. "We had a progress report on all of the projects we're working on. A project tracker so to speak. They liked that because it identified the problem you were working on, what your plan of correction was, who was responsible for it, and then follow up," she says.
"Your environment of care documents and, of course, your staffing effectiveness and patient flow data are really big — how do patients get in and out of your organization and what are your problems associated with patient flow and showing what you did about that problem? So tell a story. You have to do now an analysis of a high-risk process, and that analysis is not a failure mode effects analysis. They want you to look at a process — what are your risk points, what have you done about it?"
Phillips chose to share the process for bar coding medication administration. And share it as a story — "that's what you need with your performance improvement; it needs to tell a story," she says. Surveyors want to see your analysis, why you chose that particular process, who the team players at the table were, and whether the process crosses interdisciplinary lines.
Surveyors also praised the hospital for its work on implementing a medication reconciliation process. "We use Meditech, and we have a customer-defined screen on admission where we capture the patient's medications. That screen flows to the discharge, and it can be used as an order sheet," Phillips says. That information continues through to discharge with physicians able to mark either continue or modify each medication, as well as add new medications. Surveyors suggested that if the physician offices had Meditech as well, the med information could be stored so it was easily accessible to the next provider of care.
Going forward, Phillips says, the hospital will continue to work on the NPSGs to ensure every element is completed. "Flow of information was really important in this survey," she reiterates.
"Performance improvement data, in particular, how they get up the chain to administration and the board and how they flow down the chain to the staff level. The expectation is that your staff know your percentage in compliance rates. Even if it's organizationwide, they expect the staff to know what your organizational compliance is and to know how their specific unit fits into that compliance. Sometimes when you're the frontline caregiver, you know where you stand reasonably speaking, but specifically the average nursing assistant might not know that," she says.
You have to provide minutes of how that information flowed up and down. "I can't enforce enough whoever is responsible for the survey, having those documents ready and staying in tune to that survey activity guide" is important, she says, adding that which documents are required changed at the very end of 2008.
There also was a focus on last year's Goal 16 on rapid response. Phillips says surveyors looked at data and whether your resuscitation data show an increase in your rapid response and a decrease in your code rates. "Are you effective? That's the key thing: Is it effective and how do your data show that what you're doing is effective and has worked or do you need to go back to the drawing board and change what you're looking at? Of course we had done well with that. Our rapid response events have gone up and our code events have gone down. That's what you expect to see with that and indeed that is what happened with us."
Surveyors also looked at the timeliness of history and physicals and that your orders are dated and cosigned and timed within the 48-hour required time line.