Are You Ready for a JCAHO Survey?
Nurses will play a major role in BWH’s upcoming, unannounced JCAHO hospital and laboratory surveys, which will happen anytime in 2007. The JCAHO’s patient tracer method will drive the survey process, as surveyors select certain patient charts and “trace” those patients’ care throughout the organization, questioning staff who cared for them.
“Nurses shouldn’t be nervous or afraid to talk to the surveyors,” said Diane Lancaster, PhD, RN, Nursing’s director of Quality Measurement and Improvement. “They want to know about what nurses do everyday, and feedback that we receive from the JCAHO may help us to improve our practice.”
Test your level of survey preparation with these sample questions that a surveyor may ask nurses. Stay tuned for more information in November and December, when nurses will receive a pocket guide handbook with information to help prepare for the upcoming surveys.
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1. Describe the process you follow when conducting the assessment for a new patient.
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2. What pain assessment tools do you use for initial assessment and re-assessment?
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3. How often is pain re-assessed?
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4. If a patient were to have a latex allergy, where would this be noted? How would it be communicated to other disciplines?
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5. What triggers a nutrition rehab consult when staff are completing a patient assessment?
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6. What triggers you to consider a rehab consult? Tell me the process.
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7. How are patients screened for possible abuse (for example, elder, child, domestic violence, etc.)? What resources are available to you?
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8. How do you educate patients? Do you give them any written materials? Where is this documented in the patient record?
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9. Do you perform waived tests? Which tests? Where are the results of these tests documented in the medical record?
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10. What two methods of assessment are used to evaluate the competency for the glucometer?
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11. How do you know when quality control has been performed on the urine dipstick bottles?
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12. What should you do when you receive a critical test result via the phone from the lab?
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13. How is interdisciplinary care planning performed?
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14. What is the nurse’s role during procedural sedation?
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15. What is your role in the care of a patient who requires restraint?
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16. Can patients bring in medications from home? What is your policy?