MD hospital avoids hand hygiene RFI, finds areas for improvement

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Identify ways to improve survey results on standard MM.3.20

Multiple mock surveys prove to be one of the best ways to prepare staff members and hospital systems for unannounced Joint Commission surveys.

Mary Williams, RN, Joint Commission (formerly JCAHO) regulatory coordinator at Peninsula Regional Medical Center in Salisbury, MD, orchestrated three mock surveys before the unannounced survey in December 2007.

The 375-bed hospital, located 29 miles from Ocean City, MD, created a J-code to notify medical staff, managers, and supervisors when the survey or mock survey was taking place.

"Staff were familiar with this code and were trained to respond quickly," says Williams. During the practice surveys, Peninsula used executive staff members as overseers, which added tension and proved useful when the survey team arrived.

"When the real survey took place, the surveyors were in the lobby at 7:30 a.m.," she says, "We found the notice online at 7:25 a.m., so we knew for a few minutes they were [on their way]."

However, Williams had not considered taking the unique dynamic of the surveyor team into account.

"They're a team, and each survey is going to be different because of how the team interacts," she says. "It's important to remember that and be flexible."

Still, Williams says, "The mock survey tracers we did
. . . were the most valuable thing in uncovering issues. If we hadn't done this [survey preparation] early, I would have been behind the ball in critical values."

Williams says she plans to start another round of mock surveys as soon as the hospital completes the requirements from the previous survey.

Following the survey team

At the beginning of the survey, after the initial discussion, the team asked for a member from the information services department to accompany each tracer team to be sure that surveyors were able to access all needed data from the systems they might encounter.

"We are a wired hospital but hadn't taken [difficulty in accessing data] into account," says Williams.

Peninsula ran into challenges with MM.3.20 (medication orders are written clearly and transcribed accurately). The surveyors stressed stricter protocols and instructions around what may seem obvious, but required documentation. "It's not dumbing instructions down-you're mistake-proofing it," says Williams.

Double-checking information at the end of the day was also overlooked. "Because you're constantly providing information, you have to know about all the things you're handed and make sure they are put in their proper place, signed, dated, and filed," says Williams. The hospital was cited for not providing a preanesthesia report, but she says this was a specific mix-up in communication in which the report was separated from its chart.

Even though it ran into some problems with the survey, Peninsula was told by the surveyors that it was the first hospital that didn't have an RFI for hand hygiene in 2007. Williams says they've worked hard to keep staff members enthused about hand washing and disease control, so this was a well-deserved accomplishment.

Other areas the hospital must improve include unapproved abbreviations and dating and timing of orders.

"Since the survey, we've started using time clocks for dates and times. This makes it easier and reduces risk on anything that's not done electronically," says Williams.

Small steps toward error-proofing any sort of documentation reduce risk for any future RFIs.