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JCAHO’s top five Type I’s include clinical staff lapses
Most providers dread the microscopic inspection a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) review brings. Hospices are no different. They spend months preparing and breathe a sigh of relief after the reviewer has left.
Whether your hospice is preparing for review and is focused on meeting specific standards or whether you’ve recently gone through the process, it’s easy to use the review as an exercise rather than a process that will lead to long-term quality improvements.
According to JCAHO data from surveys completed in 1998, the most common Type I recommendations were:
1.Standard LD.7 — Defining hospice services in written contracts.
2.Standard IM.9.20 — Documenting medication, and medication allergies and sensitivities.
3. Standard TX.2 — Obtaining and updating physician orders.
4.Standard HR.6 — Assessing, maintaining, and improving the competence of staff members.
5.Standard IM.9.13 — Maintaining proper documentation of care planning activities in the patient record.
On the surface, lapses in these standards may not seem like much. Your hospice may do a good job of checking medications and communicating with physicians about changes in patients’ care plans. But the culture of hospice has caused many to place less emphasis on making sure these items are documented.
"If you ask staff, they would probably say they could care less about Joint Commission accreditation," says Karlene Conrad, RN, director of hospice for the Hospice of Northern Virginia in Falls Church, VA. "Hospice nurses are more concerned with meeting the needs of the patient than with meeting regulations. As an organization, however, we believe Joint Commission accreditation is critical. We need it to get contracts."
Mary Labayak, MSW, president and chief executive officer of the Hospice of the Florida Suncoast in Largo, FL, says this attitude is partly based on understandable reasons. Hospice standards are more akin to home health than to hospice care. Because of home health’s formalized infrastructure, many home health nurses moved into hospice care to escape the growing focus on items not directly associated with patient care. But Labayak points out that hospices must now begin to break down this culture that shows contempt for paperwork.
"If paperwork is better, care is better," Labayak states. "Obviously in this environment, you have to do both care and paperwork."
Just because documentation-related standards are common Type I recommendations does not mean that hospices are not performing necessary duties, such as care planning. But from reviewers’ perspectives, if there isn’t a written record, the tasks never occurred. From the broader quality perspective, proper documentation allows for better interdisciplinary communication and helps avoid unnecessary mistakes.
The top documentation issue, according to the Joint Commission, is the keeping of medication information. Nearly 27% of hospice organizations surveyed last year scored 3, 4, or 5 on Standard IM.9.20.
The drill is common. Hospice nurses question patient and family about medication the patient is taking — both prescription and over-the-counter — and check the home for other drugs they may have inadvertently excluded. With changes in physician orders, nurses note the update in prescribed medication and dosage. Yet, the observations and changes communicated to the nurse fail to find their way to the patient record.
Peggy Pettit, RN, vice president of patient and family services for Vitas Healthcare Corp. in Miami, blames the volume of data that nurses must collect, which is made more difficult because they are working off a handwritten system.
According to Pettit, Joint Commission reviewers cited Vitas’ approach to this problem as a good example of how to keep up documentation of medication use and changes over time. To begin, Vitas stresses diligent medication checks. After every visit, nurses are told to check medication and determine compliance with prescribed medicine and include results on a medication chart.
Next, each time a change is made to the medication record, the change is entered into a central computer. This allows other disciplines or shifts to have access to the patient’s latest medication information.
"Human error is the reason why documentation doesn’t occur," Pettit says. "Automation helps reduce human error."
While automation can help, nurses must still be accountable for making the updates and documenting changes, says Conrad. In order to ensure proper documentation, hospices must step up a process of checks and balances to promote proper behavior and modify poor documentation habits.
Conrad describes this process as a chain of accountability that begins with the nurse who must ask the patient and caregiver about medications and prescription compliance. The next link in accountability chain is a clinical manager who needs to diligently monitor nurse behavior and offer remedies for those who consistently fail to meet documentation standards.
At Hospice of Northern Virginia, a review of each patient’s medication is done every 14 days during interdisciplinary team meetings. If there is a discrepancy between medications currently being taken and those noted in the patient record, the clinical manager is responsible for working with the staff member to bring him or her into compliance. But Conrad admits that bringing staff into compliance after years of relaxed documentation can be difficult.
"It can be a real struggle because it is a culture problem," she says.
Keep updated physician orders
Another common documentation problem is failing to keep updated physician orders. Physician orders change regularly, as doctors react to the changing condition of the dying patient. Often, these changes are made verbally with a written order expected to follow.
However, in the course of treating the patient, nurses often forget to follow up with the physician and get a written order. Or perhaps the written order is received but not placed in the patient record.
"The biggest mistake is that because we work with standing orders, [nurses] forget to put new orders in the chart," says Conrad.
Both accuracy and timeliness are issues providers must be concerned with when it comes to physician orders, says Pettit. Across the hospice industry, providers are having difficulty getting their nurses to not only keep a complete collection of physician orders, but also update the orders in a timely fashion.
The same problems are also seen in clinical staff’s documentation of care planning activities, which include communication with physicians and interdisciplinary meetings or discussions regarding patient care planning.
According to both Pettit and Conrad, the best way to ensure compliance is routine audits of the patient charts and routine inservice training to stress the importance of this task.
At Vitas, hospice managers conducted inservice training that included clinical staff input. Management stressed the importance of keeping an accurate and updated patient record. But rather than impose solutions that originated from management, staff are asked to help solve the problem by coming up with suggestions to improve the documentation process. "This way you get immediate buy-in from the medical staff," Pettit says.
The most successful way to achieve organizationwide compliance is audits. "The things you check on is what people will follow up on," Conrad observes.
The audit process introduces both team and individual accountability, adds Pettit.
Document staff competency
Nurses at the Hospice of Northern Virginia are subject to several levels of audits. The first is a self-review of their own documentation. The second level involves the clinical manager who conducts spot reviews of selected charts looking at each provider’s performance. The third level is performed by the organization’s quality improvement team, which calls for a review of 10% of each region’s charts.
In order to facilitate behavior change, clinical staff must receive individual feedback from audit results. At Vitas, clinical staff who exhibit tendencies to update physician orders and perform other documentation tasks, are given one-on-one direction from their clinical manager. If the problem persists, the employee is placed in a counseling mode where the clinical manager is more directly involved promoting compliance.
"Most get turned around by this point," Pettit says. "Occasionally someone is told to seek another profession."
Type I recommendations are not always the fault of clinical staff. A frequently overlooked standard deals with assessing, maintaining, and improving competence of staff members or at least proving that there is a process to do so. This is a responsibility that falls squarely on management.
"This is so important, because you’re getting more and more critical patients," says Conrad. "You need to show that you have the skills to handle them."
"It’s important to ensure competence, especially when you’re dealing with staff that are going into the home," says Pettit. "Because no one is in the home to look over their shoulder, you have to trust that they are competent."
Hospice of Northern Virginia holds "skills days" for each of the disciplines involved in patient care. This inservice training has a similar feel to a health fair, with different stations dedicated to specific tasks. Staff members go from station to station to receive training in various competencies, with management documenting each session and noting the worker’s ability to demonstrate competency in each task.
In addition, each staff member is required to submit a self-reported skill assessment, where the staff member indicates his or her confidence in performing the tasks he or she has received training. If the staff member indicates that they would like additional training, remedial training is scheduled.
At Vitas, inservice training is also part of maintaining staff competency. In addition to inservice training, there is also a testing component, the results of which are used to document staff competency. The testing begins at the time of hire. After a three-week orientation, new clinical staff are tested for basic skills and asked to fill out a needs assessment, indicating their level of comfort in performing specific skills and whether additional training is needed.
For the rest of the organization, all disciplines are subject to pain and symptom management tests on an annual basis.
All these recommendations have a common theme: Missing documentation does not translate into missing or poor care. Often, clinical staff take on the attitude of "what does it matter if the patient is being treated well." That is the challenge managers will have to overcome if they are going to resolve the documentation problems described above.
To get there, Pettit recommends stressing the importance documentation has in the success of your organization. For example, illustrate the role documentation plays in reimbursement or winning contracts.
"The chart is a picture of what they do and how their peers are going to view their care," Pettit says. "You want it to be as accurate and up-to-date as possible."