Language adds twist to unannounced survey

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Hospital learns from a unique surveyor team

Hospitals can prepare for their Joint Commission (formerly JCAHO) surveys through several methods. However, one thing they cannot predict and prepare for is the survey team itself and the personalities of the surveyors. In May, a Spanish-speaking anesthesiologist was part of the team that visited Presbyterian Hospitals of Greenville (TX) and Commerce, part of the Hunt Memorial Hospital District.

Representatives of this 201-bed hospital said they had a successful and smooth survey—but it was the team itself that caught them off guard.

“Besides being a Spanish speaker, the anesthesiologist had a very specific focus,” says Bambi Pish, RN, MSN. “He was very black-and-white about interpretations and regulations. His specific focus led to a more concentrated review in the anesthesia department.”

The anesthesiologist surveyor spoke with the Spanish-speaking patients in the hospital. “This was awkward because we didn’t know what he was saying,” Pish says. “He sought out Spanish-speaking patients, and it was unsettling when we didn’t know what they were discussing.”

The hospital didn’t receive an RFI in regard to language or communication issues, but the nurses and staff members were caught off guard.

As well as speaking Spanish, the additional time the anesthesiologist surveyor spent in the operating rooms led to some RFIs for Presbyterian Hospitals. Although the syringes were labeled on the anesthesia table, they did not have the dose of medication on the label.

The facility was also cited for its method of conducting surgical timeouts.

Presbyterian had been doing timeouts after the patient was sedated, which was “how we were instructed at our last survey,” says Pish.

However, Presbyterian staff members were instructed that their timeout method was incorrect.

Some other problem areas included handwashing between changing of gloves and orders from physicians regarding sedation procedure.

“We were having the physician give orders to the MRI lab, but we can’t do this anymore,” Pish says. “The physician has to be present to assess the patient at the time of the procedure.”

The survey nurse’s straightforwardness helped with clarity, Pish says, although some staff members found it a little unsettling.

“The first few days, the staff was anxious,” Pish says.

“This surveyor was quite intense and not overly warm and friendly, which put the staff at a higher anxiety level than they would otherwise have been,” says Debra Clack, RN, BSN. “The staff was well prepared and usually feels good about surveys, but this one was especially tough due to the manner of our surveyors.”

However, Clack says the survey team dynamic was clear in its expectations and explanations.

“They were encouraging and professional. They wanted to help us learn and share their knowledge,” says Pish.

The hospital excelled in patient satisfaction in home healthcare as well as unapproved abbreviations, which they had been focusing on through utilization and communication between their medical executives, chief of staff, and physicians.