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Where are fire extinguishers? How are patients informed of their rights? What two identifiers do you use to make sure you have the correct patient? These questions were among dozens that staff on Tower 14CD and the outpatient Cardiology practice in Brigham Medical Specialties fielded during mock Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveys this month.
Gail Morrissey, BWH’s manager of Clinical Compliance, and members of the Ever Ready Team, including executive leadership, are conducting the readiness surveys to prepare staff for BWH’s upcoming, unannounced hospital and laboratory JCAHO surveys, which can occur anytime in 2007.
“Everyone did very well during our first round of readiness surveys,” Morrissey said. “Staff articulated how they do their jobs each day and demonstrated their compliance with and knowledge of hospital policies, and that’s what surveyors want to see.”
During the practice survey in Cardiology, Morrissey and Sharon Vitti, vice president of Clinical Services, played the part of JCAHO surveyors and examined equipment, rifled through drawers and cabinets and quizzed staff about their responsibilities—just as JCAHO surveyors will do to assess compliance.
One week later, Chief Operating Officer Kate Walsh joined Morrissey to survey Tower 14CD, and they questioned nurse manager Cindy Lemay, RN, and staff about patient care responsibilities, toured the unit and reviewed a patient’s plan of care.
During both surveys, Morrissey deviated from her surveyor role to give staff tips that will come in handy for the real survey. For example, when she asked Tower 14CD patient care assistant Patricia Dabel what number she would call to report a code, Dabel turned to the back of her identification badge for the number (ext. 2-6555). “If you don’t know the answer to a question but know where to find it, let the surveyor know,” Morrissey said.
The JCAHO’s patient tracer method will drive the JCAHO survey process. Surveyors may select certain patient records and trace those patients’ care from admission to discharge. They will question many staff involved in the care of these patients, examining how they follow standards. Surveyors also will trace patients seen in BWH ambulatory sites both at the hospital and at off-site locations.
From left, Sioux Gilli, Gail Morrissey, Kelly Mihalic, Susan Jackiewicz and Sharon Vitti relax after the practice survey of the Cardiology practice in Brigham Medical Specialties. Survey Stars Kudos to these staff who proved they are ready for an unannounced JCAHO survey. Cardiology, Brigham Medical Specialties Sara Guterman, clinic secretary. She explained the protocol she follows for checking in patients and informing them of their rights. Katia Powell, medical assistant. Powell responded to a series of questions about her responsibilities, including how she calls for patients in the waiting area and verifies that she has taken the correct patient into the exam room. “I ask their name and date of birth,” Powell said. She also explained the protocol for a patient with MRSA, showed Morrissey where to find MSDS sheets and demonstrated correct hand hygiene technique. Kelly Mihalic, practice coordinator, Sioux Gilli, administrator, and Susan Jackiewicz, associate clinical administrator. They guided Morrissey and Vitti on a tour of the practice, fielding questions that spanned the range of JCAHO requirements, including what steps to take in a Code Amber, what quality improvement projects the practice initiated in the last year and where patient problem lists are maintained. Tower 14CD Cindy Lemay, RN, nurse manager, and Kelly Brennan, RN, nurse educator. They reported on the quality improvement initiatives the unit recently piloted, including the Rapid Response Team and the Pre-Admission Medication List, the hospital’s new medication reconciliation application. They answered questions about the process for communicating critical test results, decreasing usage of restraints and documenting the use of restraints. Heidi Unger-Dowd, RN. She answered questions about a patient’s pain assessment and described the hand-off communication between the PACU and 14CD that occurred after the patient recovered from surgery. Patricia Dabel, patient care assistant. She detailed her role in a fire and how the unit is decreasing patient falls. From top: Gail Morrissey observes as Tower 14CD’s Kelly Brennan, RN, and Cindy Lemay, RN, demonstrate proper hand hygiene technique. Morrissey and Kate Walsh review a patient’s chart with Heidi Unger-Dowd, RN, on Tower 14CD. Katia Powell shows Morrissey where the precaution gowns are kept in the Cardiology practice in Brigham Medical Specialties. Patricia Dabel of tower 14CD answers Morrissey’s questions about what to do in a Code Red situation. Are you ready for a JCAHO survey? Test yourself with this sample list of questions a surveyor might ask during BWH’s hospital and laboratory surveys, which can occur anytime in 2007. What is a Code Gray? What number do you call to report a code situation? How do you protect patient confidentiality and keep patient information secure? Where are the fire extinguishers? Where is the patient problem list maintained? What is the process for getting rid of hazardous materials? Where do you keep needles and syringes? What is the process for communicating critical test results? Demonstrate hand hygiene. Do you know the National Patient Safety Goals? Name one goal and the hospital’s policy for complying with it. 2007 National Patient Safety Goals Improve the accuracy of patient identification. Improve the effectiveness of communication among caregivers. Improve the safety of using medications. Reduce the risk of health care associated infections. Accurately and completely reconcile medications across the continuum of care. Reduce the risk of patient harm resulting from falls. Encourage patients’ active involvement in their care. The organization identifies safety risks inherent in its patient population.
Kudos to these staff who proved they are ready for an unannounced JCAHO survey.
Cardiology, Brigham Medical Specialties
Sara Guterman, clinic secretary. She explained the protocol she follows for checking in patients and informing them of their rights.
Katia Powell, medical assistant. Powell responded to a series of questions about her responsibilities, including how she calls for patients in the waiting area and verifies that she has taken the correct patient into the exam room. “I ask their name and date of birth,” Powell said. She also explained the protocol for a patient with MRSA, showed Morrissey where to find MSDS sheets and demonstrated correct hand hygiene technique.
Kelly Mihalic, practice coordinator, Sioux Gilli, administrator, and Susan Jackiewicz, associate clinical administrator. They guided Morrissey and Vitti on a tour of the practice, fielding questions that spanned the range of JCAHO requirements, including what steps to take in a Code Amber, what quality improvement projects the practice initiated in the last year and where patient problem lists are maintained.
Tower 14CD
Cindy Lemay, RN, nurse manager, and Kelly Brennan, RN, nurse educator. They reported on the quality improvement initiatives the unit recently piloted, including the Rapid Response Team and the Pre-Admission Medication List, the hospital’s new medication reconciliation application. They answered questions about the process for communicating critical test results, decreasing usage of restraints and documenting the use of restraints.
Heidi Unger-Dowd, RN. She answered questions about a patient’s pain assessment and described the hand-off communication between the PACU and 14CD that occurred after the patient recovered from surgery.
Patricia Dabel, patient care assistant. She detailed her role in a fire and how the unit is decreasing patient falls.
Test yourself with this sample list of questions a surveyor might ask during BWH’s hospital and laboratory surveys, which can occur anytime in 2007.