Wills Memorial Hospital

1
Welcome

• Wills Memorial Hospital
• Briefing on Our
• Joint Commission on Accreditation of Healthcare
  Organizations Survey
• October 26-27 2006
• Presented By
• Jane Echols, Director of Nursing
• Bruce Bailey, JCAHO Coordinator

2
NOTIFICATION
On JCAHOs extranet (jayco) website at 0700 along
with profile and picture of surveyor. The
Surveyor was waiting outside the front entrance
at 0730. Did not enter until 0745.
3
PRELIMINARY PLANNING SESSION

• Asked to have the following (As described in the
  Surveyors Guide Book)
•  
• Daily Census and Surgery Schedule
• Organizational Chart Administrative and
  Department
• Organizational Map
• Committee Structure Diagram
• Statement of Conditions Specifically Part 4

4
PRELIMINARY PLANNING SESSION
6. Medical Records Delinquency Data 7. Organ
Donation and Procurement Conversion Rates 8.
ORYX Data 9. PI Data 10. Asked if we could move
Medical Staff Credentialing and Privileging to
day 2 after lunch and in place put Competence
Assessment Process. 11. Asked if we could have at
least 3 board members present for the
leadership session in the am.
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PRELIMINARY PLANNING SESSION
Also, wanted Medical Staff/Medical Executive
Committee meeting minutes for the past year along
with the Hospitals Medical Staff Bylaws / Rules
and Regulations to review while the management
team was assembling.
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OPENING CONFERENCE
The conference started with the Surveyor asking
the administrator to tell him about our facility
in his own words. i.e. what is the population
served and services provided? Have we cancelled
any services except OB since our application was
filed? What is the make up of your hospital
authority? What is the status of your surgical
clinic?
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OPENING CONFERENCE
Introductions of our department heads present
surveyor asked our radiology dept. head if we had
a full-time Radiologist and if not, does the
pharmacist review all contrast study orders prior
to administration or is the LIP present at time
of administration? Asked the respiratory dept.
head if she had a system in place for the
respiratory therapist to have the medication
double checked prior to administration?
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OPENING CONFERENCE
Asked if the hospital had a specific protocol for
the response to a pediatric code? Asked if we
used the Broselow system and if so did we use the
tape for drug references? Asked the maintenance
dept. head if he did fire drills and how often?
Also wanted to know if we tested the generators
on a load and how much of a load?
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CONTINUED SURVEYOR PLANNING
The surveyor reviewed the minutes from the
Medical Staff meetings and the Medical Executive
meeting. Surveyor reviewed our Medical Staff
Bylaws/Rules and Regs.
10
Life Safety Code Building Assessment
  Surveyor reviewed the part 4 form of our
Statement of Conditions. TOUR First thing wanted
a Floor plan with smoke and fire dampers drawn
in, also with elect shut offs, Gas shut offs, and
water. Checked smoke barriers above ceiling for
holes x3. Made sure there were less than 12 E
oxygen cylinders in storage on floor. Did not
like clutter in shop or building. Was very big
even about organized clutter. Wanted to check
roof for cigarette butts.
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Life Safety Code Building Assessment
Asked employees about what they should do if
splashed in eyes with chemicals. Wanted to know
how often eye wash stations were purged. Checked
every fridge log in Dietary. Checked every fire
door for proper closer. VERY STRICT! Checked for
18" clearance to ceiling in all storage areas.
Stickler about hair covers in Dietary. Trash
cans being full were noted in many areas. Wanted
to know what every piece of equipment was in
boiler room and its purpose.
12
Life Safety Code Building Assessment
Where were our MSDS books located? Where is the
fuel tank located for generator? Checked every
fire extinguisher he saw for inspection
dates. Wanted to see a K rated extinguisher in
dietary kitchen. Noted pan condition in
kitchen. Every thing must be off the floor on
crates. Looked at ever storage area and
equipment room. Looked for out of date stuff in
materials store room.1st time that's been
done. Checked flammable storage room for tight
seal on door.
13
Life Safety Code Building Assessment
Inspected smoking area. Checked Bio Hazard
storage area for temp and lock. Who has
permission to shut down oxygen? Wanted to know
how often we do Environmental Tours.
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Individual Tracer
Surveyor reviewed an inpatient chart that had
surgery the day before. Started with HP on
admission for time and content. Was very big on
what is documented in the physical exam on the
HP. Reviewed the physicians orders for
abbreviations, range orders, times and dates on
orders, physician co-signature on telephone and
verbal orders. Reviewed nurses notes for pain
management, abbreviations and assessments.
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Individual Tracer
Looked at the surgical portion of the chart for
updated HP, pre-anesthesia and post-anesthesia
plans, Time out (Time before and in OR),
Medications used during surgical procedure,
CRNAs notes and times, PACU notes, and orders
upon release from recovery back to the medical
surgical unit. Requested employment files be
pulled from personnel that were involved in this
patients care.
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Competence Assessment Process
Employment records pulled for the following
categories ER Nurse Respiratory
Therapist CRNA Dietician Pharmacy Tech Nurse who
entered pharmacy last DON Nursing Supervisor
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Competence Assessment Process
Surveyor started with initial training of
employees. Looked to see if all of the initial
training had been completed and all blanks
checked and signatures in all places where
needed. Concentrated very heavily on Cultural
Diversity training and how we did it. Wanted to
see license and certifications. Compared with
what was current and listed on Job
Description. Asked how we trained our staff
ongoing. How do you maintain competencies in
skills BLS, ACLS, PALS, Trauma? Was very strict
on all signatures in place and blanks checked.
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Individual Based System Tracer Data Use
Surveyor looked at 3 charts Swing bed patient,
inpatient, and observation patient. Reviewed the
ER triage assessment and orders for patients in
the ER. Looked to see if any patients went to
radiology, if so how was it documented and
patient followed.
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Individual Based System Tracer Data Use
Looked at Admission Assessment and reviewed it
for all parts wanted to see pain assessment
questions and how deep we went into asking about
pain looked at dietary assessment and how soon a
dietician would see the patient if needed looked
at the dental assessment PT/OT assessment lab
values and time ranges on how long it takes for
critical lab values to be reported to the PCP,
wanted this in a graph format for tracking
looked at physician orders and found 2 qds on
the chart and then went to the MAR to see if the
pharmacist changed it to q day. Reviewed for the
physician writing range orders and the use of the
variable (only one variable should be used)
recommended that the variable be the dose not
time and that the highest dose not exceed 4 x the
lowest dose.
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Individual Based System Tracer Data Use
Wanted to see how we trained visitors and
correctional officers on patients rights and
responsibilities. Reviewed the privileges on the
PCPs that admitted the patients. One PCP did not
want to do central lines and one did, asked how
we track to see how many the one requesting
central line insertion privileges did during his
term. Asked what other privileges we tracked for
the physicians, not covered in the M.S.
Bylaws/RRs. Wanted to know if we received the
updates from ISMP and who reviewed them. Wanted
to know why a PCP wrote for a venous study but
did not clarify of what.
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Special Issue Resolution
Asked for 3 charts from the last three surgical
procedures. Asked for 3 charts from the last
three IV Contrasts in radiology. Asked for 2
charts from the last sleep study completed
here.   All of these to be ready for the next
morning.   Completion of Day 1
22
Leadership Session
Surveyor asked for introductions of all
present. Asked the Hospital Authority members the
following How they are appointed? How do they
ensure that a good cross section of the community
is represented? How long is their term? How long
have each been on the Board?
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Leadership Session
Asked if they were involved in operations of the
hospital? Asked if they were invited to sit in on
the Medical Executive Committee Meetings? Did
they understand all of the medical jargon that is
thrown at them and are they able to ask questions
to help them understand it? Asked them when they
receive their packets before a board meeting what
do they look at first and why?
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Leadership Session
Asked them if they knew what a sentinel event
was? Have you had one here and if so, since it is
voluntary to report it, would you? Asked how they
assess the performance of the hospital?
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Individual Tracer
Surgical Tracer Surveyor started reviewing the
charts requested from the previous day. I
escorted him to our surgical department. Wanted
to know who performs the pre-anesthesia
assessment? Wanted to know who performs the
pre-anesthesia assessment on the patients for the
Dentist and the Podiatrist? Wanted to know if the
physicians documented rectals, pelvics, and
breast exams.
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Individual Tracer
Wanted to see the Surgical Privileges book for
the physicians with surgical privileges. Reviewed
the privileges for the general surgeons and
wanted to see hospital specific privileges and
ensure that we could perform those procedures
here. Looked at the local PCPs to see what they
were allowed to do and asked how we tracked how
many procedures they did per year? Looked in our
surgical suite and looked at humidity control and
temperature.
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Individual Tracer
Reviewed the sterilizers for spores being
performed. Looked at our steris machine and asked
how often we serviced it. Looked in the PACU and
opened the code cart. Wanted to know why we kept
a bottle of epi 11000 on the cart along with
pre-filled syringes of epi 110,000 and ensured
we had them labeled. Concentrated on looked a
like, sound alike. Asked if we kept ampules of
epi 11000 on the code cart? Asked if we diluted
the epi 11000 we had on the cart before
administration?
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Individual Tracer
Looked at the medication cabinet to ensure we
were logging counts as per policy. Looked at the
refrigerator to ensure we are monitoring
temps. Recommended getting an after market alarm
to do away with logs. Asked if we did conscious
sedation in the OR? Asked if we did conscious
sedation in the ER before cardioversion or when
reducing fractures or out of place
shoulders? Asked if nurses used Proporfol?
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Individual Tracer
IV Contrast Tracers Asked if a pharmacist reviews
all orders for IV, Oral, Barium contrast to be
administered except in emergent situations where
the ER physician orders it? If not, is a LIP
present at the bedside during administration? How
are your radiology technicians trained on
administration and evaluated yearly? How many
anaphylactic reactions have you had at this
facility? How many adverse drug reactions while
using contrast?
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Individual Tracer
How many types of contrast do you use? Who
provides the contrast pharmacy or central
supply? Where is it stored? How is it monitored
for out of dates? What must you have prior to the
administration of the contrast? Do you do
medication reconciliation?
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Individual Tracer
Who does the Barium Enemas? Have you ever had a
catheter explode in a patient? What pressure
rating are your catheters? What pressure rating
is your power infuser?
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General Nursing Questions
Do you have a fulltime pharmacist? How do you
retrieve medications when the pharmacist is not
here? What if you do not have the medication in
the night cabinet do you go into the pharmacy to
retrieve it? If so, how have you been trained to
enter the pharmacy? If you retrieve a medication
from the night cabinet do you have a system in
place to ensure that the appropriate medication
has been retrieved?
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General Nursing Questions
Do you check all the night cabinets before going
into the pharmacy? Is there specific list of
medications that the nurse can obtain from the
pharmacy? Do you do medication reconciliation on
all patients thru out the hospital? How do you
report medication errors? Are you encouraged to
report errors? What type of waived testing do you
do here? How are you trained to perform these
test and followed? How do you store insulin, and
if you keep Novolin and Novolog, do you mark it?
34
Sleep Study Tracers
Reviewed the procedure for a sleep study to be
performed. Asked if we do the study or a contract
person? How do we ensure competency for the
contracted employee? Do they do pain evaluations
prior and post study? If the patient has to take
something for sleep is it documented? Does the
Tech let the patient bring in their own meds and
if so how do they document their use? How do they
ensure that the patient is safe to drive home if
several medications are taken to help sleep?
35
Rehab Services Questions
Asked to see the PT/OT area and be given a walk
thru. Asked if they keep medications in their
dept for iontophoresis? Asked if we had patient
goals (not just therapist goals)? Asked to review
a chart and looked for pain assessment pre
treatment, during treatment, and post treatment.
36
Emergency Room Questions
Asked how is the staff trained to handle
pediatric emergencies/codes? Are all staff
required to be PALS trained? Do you have a policy
to respond to pediatric codes? Do you use the
Broselow system? If so, do you use the Broselow
tape and what edition is it? Would you use it for
medication calculations?
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Infection Control Questions
How do you monitor nosocomials infection
rates? Do you monitor surgical infection rates
and outcomes? How often do you do rounds? Do you
flush the eye wash stations, if so how often, and
for how long? Do you monitor hand-washing
techniques thru out the hospital? Do you report
to a committee? Do you report to someone from
medical staff? How does your data get reported
across the continuum of care?
38
Environment Of Care Session
Reviewed EOC and Safety min. Reviewed
Vulnerability analysis What are your
vulnerabilities? Reviewed disaster drills. When
was your last outside drill and who
participated? When was your last inside drill,
what was it, and how did you perform? Asked to
see annual evaluations of the process.
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Environment Of Care Session
Looked at Objectives, scope of plan, goals, and
did we achieve those goals. Wanted to see yearly
report of EOC to hospital board. Asked about
Safety inspections when are they performed? Asked
about Departmental safety surveys and when they
are performed? Safety walk through inspections
building and grounds. Looked at fire drill
reports (asked about water storage tanks),
sprinkler inspections, vent hood inspections,
fire damper inspections, checked equipment safety
logs after getting 's off equipment on building
tour. Reviewed the Statement of Conditions part 4
with what we are currently doing.
40
Medical Staff Credentialing and Privileging
Reviewed the credentialing packet of two General
Surgeons, one Urologist, two Medical Staff
members, and the CRNA. While reviewing the
Surgeons packet looked for licensure,
certifications, privileges requested and those
given. Asked how we ensure competencies in
performing procedures when up for
reappointment? While reviewing the Urologist
packet, looked for licensure, certifications,
privileges requested and those given.
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Medical Staff Credentialing and Privileging
While reviewing the Medical Staff physicians
packets, noticed that one physician does central
line placement and the other did not ask for that
privilege wanted to know why? Asked if we had a
list of advance/high risk procedures that must be
monitored to ensure competencies?
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Medical Staff Credentialing and Privileging
How many of these advance procedures must a
physician do to stay competent? What
licensure/certifications do we require For our
contracted ER physicians ? How do we ensure
competency? Do we monitor advance/high risk
procedures performed by the ER physicians and
report at time of reappointment?
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QUESTIONS ?