Survey challenges addressed through firsthand experience

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Every year, certain National Patient Safety Goals present additional challenges to facilities, particularly at survey time. During its recent unannounced survey, Baptist Health, a five-hospital healthcare system, servicing the regions of Duval, Nassau, Baker, Clay, and St. Johns in northeast Florida, faced some specific goal challenges, which they are now focusing on for improvement.

Mary Halvorsen, RN, BSN, senior consultant for accreditation and corporate compliance at Baptist Health, suggests that all hospitals should become familiar with the challenging accreditation requirements because chances are, performance struggles at one hospital are the same at another.

Halvorsen prepared for her facility's unannounced survey with mock tracers on a weekly basis, while incorporating this process with environmental rounds.

"We had members of this systemwide accreditation committee do mini tracers in their area of specialty: pharmacy, lab, nursing," says Halvorsen. "Focusing on specific issues made it less time-consuming than full tracers."

At the monthly systemwide accreditation committee, chapter leaders review standards and discuss corrective action planning, as well as PPR.

"We work with individuals in each area to access compliance," says Halvorsen. "We're constantly monitoring for standards compliance. The PPR is updated on a [continual] basis, so when it's time to submit, it's not a big deal."

As for staff involvement, "we have little e-mails, ticklers, and prizes on a monthly basis. This type of education focuses on the specifics staff need to know," says Halvorsen.

However, as any hospital knows, even with constant preparation, there are problems. The Joint Commission (formerly JCAHO) published a list of challenging standards and requirements in the first half of 2007; Halvorsen recommends that hospitals become familiar with these troublesome areas.

"This is what we're really focusing on this year," says Halvorsen.

Some of the most challenging standards listed include: PC.8.10 (pain is assessed in all patients), MM.2.20 (medications are properly and safely stored, and clearly transcribed), as well as EC.5.20 (newly constructed and existing environments are in compliance with the Life Safety Code®).

Additional requirements listed were:

MS.4.15—the decision to grant or deny a privilege

Goal #2B—standardize the list of abbreviations

Goal #2C—measure and assess the timeliness of reporting

Goal #3C—review and identify a list of look-alike, sound-alike drugs

"We were hit hard with physician-driven processes," says Halvorsen. "Physicians are often the hardest population to reach for education on standards and requirements because they're difficult to pull into continuous readiness and monitor for compliance."

Plans are now in place to improve physician-driven processes in the days ahead.

"In the future, we're focusing on making sure physicians are included in updates [from The Joint Commission]. They need to know it, and we need to monitor them more effectively," says Halvorsen.

Halvorsen also had a post-survey surprise.

"When the report was sent to the main office for review, we had a couple Requirements for Improvement (RFI) couched under other standards, one was downgraded from a RFI to a supplemental and one supplemental was upgraded to a RFI," says Halvorsen. "I've never experienced this much survey report rework in previous surveys."

Halvorsen plans on implementing and focusing on not only physician education improvement but also heavily on the list of the most challenging standards.

"It's a great reference, these [challenging requirements] really did line up with our struggles," says Halvorsen.

Select the Most Challenging Standards and Requirements for the First Half of 2007 link at for a complete list of these standards.