PTAN® Forum

Return to PTAN® Home Page

RESTRAINT OR SECLUSION, (TX.7.1)
   Hospitals that received a score of 3, 4, or 5:  50.5%
   What the standard requires:
		TX.7.1 requires hospitals to have processes for using restraints
		on patients and secluding them. Throughout the intent, it says
		that hospitals have flexibility and freedom in addressing these
		issues.
   Action Points:
        Review the hospital's policy on restraints and seclusion to see
		if it meets the requirements in the 1996 intent statement under
		TX.7.1.  At the very least, the restraint policy should state: 1)
		that a physician order is necessary, 2) who can initiate a
		restraint ahead of an order and how far ahead that initiation can
		be made, and 3) the frequency of observations.
        Develop a physician order form and nursing flow sheet to prompt
		staff to provide all information required in the policy.
        Establish a 100% concurrent review of all restraint order
		documentation 12 months before survey, if possible.
        Review the supplemental 1995 mental health standards, which lay
		out specific requirements.


 Return to the top 


COMPETENCY NOT ASSESSED AGAINST JOB DESCRIPTION, (HR.4)
   Hospitals that received a score of 3, 4, or 5:  32.1%
   What the standard requires:
		Focusing on nonclinical staff who have clinical contact with
		patients, HR.4 says the hospital must assess staff competency
		with attention to age-specific qualifications and the
		responsibilities and expectations stated in the job description.
   Action Points:
        Have all clinical directors review the categories of patients
		that their staff see by looking at DRG's, case mix data, and
		utilization review patterns.
        Identify the staff positions that come in contact with infant,
		youth, and elderly patients as part of their normal duties.
        List the knowledge, techniques, and/or communication skills that
		a competent staff member must possess for these positions.
        Add these requirements to the job description and performance
		appraisal form to prompt supervisors to evaluate staff on these
		skills - document that this was done.
        Identify education needs and provide training on these skills.

 Return to the top 


MEDICAL RECORDS NOT COMPLETED WITHIN 30 DAYS, (IM.7.7.2)
   Hospitals that received a score of 3, 4, or 5:  21.2%
   What the standard requires:
		IM.7.7.2 clearly states that discharged patients' medical records
		must be completed within a time frame established by the medical
		staff not to exceed 30 days.
   Action Points:
        Make sure the medical records department has a system that
		allows all physicians equal access to records as soon as possible
		after discharge.
        Work with medical staff leaders on the need for timely
		completion of records, seeking support from the medical executive
		committee, vice president of medical affairs, and/or the
		president of the medical staff.
        Be willing to change administrative approaches, where feasible,
		to make record completion more physician-friendly.
        Consider positive incentives for timely completion, such as
		noting in the medical staff newsletter which physicians met their
		completion goals.
        Consider more creative disincentives; for example, encourage the
		medical staff and the board to develop a voluntary resignation
		policy for physicians whose records are delinquent for more than
		three months in any 12-month period.
        Consider setting up a concurrent review program, in which
		medical records staff check records and notify physicians of
		omissions while the patient is still in the hospital.

 Return to the top 


NARROW SCOPE OF ASSESSMENT OF PATIENTS, (PF.2.1.1)
   Hospitals that received a score of 3, 4, or 5:  20.7%
   What the standard requires:
		PF.2.1.1 says that hospitals must consider cultural and religious
		practices, emotional barriers, desire and motivation to learn,
		physical and cognitive limitations, and language barriers when
		conducting the educational assessment. (In 1996, hospitals must
		also consider the financial implications of care choices.)
   Action Points:
        Considering cultural and religious practices trips up most
		hospitals-they just don't do it or at least don't document it.
        Include questions in the education assessment form on the six
		areas mentioned in the 1996 standard.
        Educate nursing staff to look for and document that these needs
		were assessed.
        Consider doing a concurrent chart review, perhaps by an evening
		charge nurse, to assess compliance.







 Return to the top 



NONCOMPLIANCE WITH LIFE SAFETY CODE, (EC.1.1.1)
   Hospitals that received a score of 3, 4, or 5:  17.7%
   What the standard requires:
		EC.1.1.1 state that the hospital must use the 1991 edition	of
		the NFPA-101 Life Safety Code published by the National Fire
		Protection Association as a criteria for life safety. (Compli-
		ance with the Code is assessed by a hospital using the Statements
		of Condition to identify all Code deficiencies, after which the
		surveyor corroborates the hospital's findings during the building
		tour.)
   Action Points:
        Make sure you understand which buildings need an SOC completed;
		the JCAHO may soon come out with more definitive criteria.
        If you decide to complete the SOC internally, make sure the most
		knowledgeable staff are involved, and consider going through the
		inspection process several times to be sure no deficiency has
		been missed.  Code deficiencies not disclosed on the SOC will
		lead to problems.
        If you hire an outside consultant to complete the SOC, make it
		clear in the language of the contract that his or her firm is
		responsible for what is reported in the SOC.  A few hospitals
		have hired consultants and have been burned at survey time.
        Many experts believe that hospitals have enough in-house know-
		ledge to complete 80-85% of the SOC, so consider using a consul-
		tant for part of the job to save time and money.
        For the findings in the SOC, develop individual plans for
		improvement (PFIs) with time frames and get signed assurance of
		resource support from administration.
        Prioritize the order of PFI completion by the risk the Code
		deficiency poses to patients, not the cost of fixing the problem.
        Include review of any life safety concerns in regular hazard
		surveillance inspections.
        Carry an up-to-date blueprint during the survey showing smoke
		walls; this may help eliminate confusion over the location and
		type of life safety structure.

 Return to the top 


INADEQUATE EMERGENCY MEDICATION SYSTEM, (TX.3.2.7)
   Hospitals the received a score or 3, 4, or 5:  16.7%
   What the standard requires:
		TX.3.2.7 says a hospital must have an emergency medication system
		in place.  The intent states that the process ensures the avail-
		ability, control, and security of these medications.
   Action Points:
        Work with the pharmacy director to establish an updated emer-
		gency medication inventory that can be-according to policy-left
		under the control of the director of nursing or her on-site
		designee during periods when the pharmacy is closed.
        Establish policies and procedures-approved by the P&T committee-
		for gaining access to this inventory and have a log to record
		usage.
        Communicate with and/or train appropriate line staff about the
		policy.


 Return to the top 


INADEQUATE EDUCATION ON FOOD/DRUG INTERACTIONS, (PF.2.2.3)
   Hospitals that received a score of 3, 4, or 5:  15.2%
   What the standard requires:
		PF.2.2.3 requires hospitals to instruct patients on potential
		food/drug interactions and nutrition.
   Action Points:
        Have pharmacy and dietary staff develop a list of medications
		that constitute high risk for food/drug interaction.
        Group these medications in categories based on required dietary
		restrictions.
        Develop consistent instructional materials to educate patients
		on the risk of these interactions.
        Provide training to all staff-especially dietary, pharmacy, and
		nursing-who are responsible for educating patients.


 Return to the top 


AGE-SPECIFIC ASSESSMENT NOT DONE, (PE.7)
   Hospitals that received a score of 3, 4, or 5:  14.7%
   What the standard requires:
		PE.7 addresses the need for individualized assessment and re-
		assessment of infants, children, and adolescents. (In 1996,
		hospitals must also begin assessing age-specific emotional,
		cognitive, communication, educational, social, and daily activ-
		ities needs, as well as effect of the family or guardian on the
		patient's condition, and vice versa.)
   Action Points:
        Using the 1996 intent statement for PE.5, create a standard
		assessment form (a checklist) for infants, children, and ado-
		lescents that considers the five things listed in the intent.
        Revise the nursing policy as needed and inform staff of the
		expanded assessment, providing necessary training.


 Return to the top 


CHALLENGES TO PHYSICIAN LICENSURE OR REGISTRATION NOT CONSIDERED, (MS.2.5.1)
   Hospitals that received a score of 3, 4, or 5:  12.0%
   What the standard requires:
		MS.2.5.1 states that during appointment or reappointment, infor-
		mation regarding successful or pending challenges to a physi-
		cian's licensure or registration or the voluntary or involuntary
		relinquishment must be disclosed.
   Action Points:
        Check your bylaws and rules and regulations to make sure they
		contain language for "voluntary or involuntary" membership,
		licensure, or privileges.  A number of hospitals get Type I's
		merely because this language is missing.
        Medical staff offices should seek complete licensure history
		information from the State Licensing Board, the Federation of
		State Medical Boards, and the National Practitioners Data Bank
		(NPDB).
        Document that the credentials committee looked at the infor-
		mation from the NPDB, perhaps by creating a standard checklist.
        Be sure to do this every two years, not just at initial appoint-
		ment.


 Return to the top 


VERIFICATION OF LICENSURE, TRAINING, EXPERIENCE, AND COMPETENCE
NOT COMPLETED, (MS.2.4.1.3.1)
   Hospitals that received a score of 3, 4, or 5:  11.7%
   What the standard requires:
	   MS.2.4.1.3.1 says hospitals must verify an appointment or clinical
	   privileges applicant's licensure, training, experience, and com-
	   petence with the primary source (only for physicians who joined
	   the medical staff after January 1, 1988).
   Action Points:
        The medical staff office or a verification service working under
		contract must provide a complete verification of the physician's
		history of practice since completing medical school. For example,
		if a hospital grants privileges to a surgeon for a procedure he
		or she has not done in years, the hospital must document that the
		surgeon has received extra training beyond residency.
        Missing time slots in the physician's work history must be ac-
		counted for.


 Return to the top 


INAPPROPRIATE CONTROL OF MEDICATIONS, (TX.3.2.2)
   Hospitals that received a score of 3, 4, or 5:  10.9%
   What the standard requires:
	   TX.3.2.2 requires that the preparation and dispensing process
	   allows for the proper control of medications.
   Action Points:
       Make sure drugs stored in carts, inpatient units, and ambulatory
	   sites are kept locked and are accessible only to authorized indi-
	   viduals.
       Keep narcotics under double lock with an authorized individual
	   who has access when needed and consider keeping a log to track
	   the use of them.
       Document compliance with hospital policies on controlling medi-
	   cations.


 Return to the top 


LOSS OF MEDICAL STAFF MEMBERSHIP, PRIVILEGES NOT CONSIDERED, (MS.2.5.2)
   Hospitals the received a score of 3, 4, or 5:  10.6%
   What the standard requires:
	   MS.2.5.2 says that information must be provided by an applicant
	   for appointment or reappointment concerning the voluntary or
	   involuntary loss of privileges at another organization.
   Action Points:
       The medical staff office should research any applicant's loss of
	   membership or privileges with appropriate agencies.
       What a physician reports in the application must match the infor-
	   mation gathered, even a voluntary loss of procedures.
       Hospitals should document that all information provided by the
	   applicant was considered.


 Return to the top 


NO ASSESSMENT OF PATIENT LEARNING NEEDS, (PF.2.1)
   Hospitals the received a score of 3, 4, or 5:  9.8%
   What the standard requires:
	   PF.2.1 states that the hospital assesses the patient's and, if
	   needed, his or her family's educational needs, abilities, and
	   readiness to learn. (In 1996, the patient's learning "preferences"
	   are added to this list).
   Action Points:
       If it doesn't already have one, the education office should help
	   develop a good, standardized education assessment tool.
       Make sure clinical staff document a specific assessment of
	   patient learning needs on a standard assessment form.


 Return to the top 


FIRE DRILLS NOT DONE AS REQUIRED, (EC.2.2.2)
   Hospitals the received a score of 3, 4, or 5:  9.7%
   What the standard requires:
	   EC.2.2.2 specifically says that hospitals must conduct fire drills
	   quarterly on all shifts.  The fire drills must include all hos-
	   pital personnel in all buildings and should check their knowledge
	   of fire procedures.
   Action Points:
       Establish an annual fire drill plan for each building, scheduling
	   quarterly fire drills for each smoke compartment on every shift.
       Observers in each area being drilled and in the adjacent smoke
	   compartments should complete a post-drill evaluation for that cri-
	   tiques the performance of staff during the drill-not merely that
	   the drill was done.
       The results of these evaluations should be summarized and re-
	   viewed by a designated group, such as a hospital life safety sub-
	   committee or the internal fire brigade.	Lots of hospitals trip
	   up here because they have difficulty documenting the results of
	   drill critiques.
       Recommendations for improvement and/or further education should
	   be made by the safety committee.
       If your hospital is under construction, see if interim life saf-
	   ety applies, and, if so, make sure the number of fire drills is
	   doubled in and adjacent to the construction area.


 Return to the top 


AUTHENTICATION OF MEDICAL RECORD ENTRIES TOO SLOW, (IM.7.9)
   Hospitals the received a score of 3, 4, or 5: 9.0%
   What the standard requires:
	   IM.7.9 says that entries in the medical record must be authen-
	   ticated and dated, and the author identified.  The intent says
	   that a process must be in place to ensure that this is done.
   Action Points:
       Review the JCAHO's list of allowable authentication methods
	   (pp. 435-436 of the 1996 CAMH) and consider alternatives to
	   signing every document by hand.
       Work with medical staff leaders to streamline the process of
	   authenticating records.
       Have the medical staff leaders encourage timely completion and
	   enforce penalties for persistent delinquency.
       Consider a concurrent review program, in which medical records
	   staff flag missing signatures while the patient is still in the
	   hospital.
       Put records still needing signatures only in areas physicians
	   visit most frequently, such as the physician's lounge or the OR.


 Return to the top 


INADEQUATE INFORMATION MANAGEMENT PLANNING, (IM.1)
   Hospitals that received a score of 3, 4, or 5:  8.7%
   What the standard requires:
	   IM.1 requires hospitals to plan and design their information
	   management processes to meet the needs of the organization.	The
	   intent lists 16 points (more in 1996) that should be  considered
	   during an assessment of those needs.
   Action Points:
       Document that you considered the 16-plus points listed in the
	   intent of IM.1.	Some hospitals have made an IM survey checklist
	   from the intent.
       Develop a list of the departments served by management infor-
	   mation services (MIS), medical records, and the library.
       Document how MIS assesses the information needs of these groups
	   and list the current services provided.
       Write down how the hospital has set priorities for improving in-
	   formation services and identified what improvements are being
	   worked on.  Most hospitals have some sort of IM plan that docu-
	   ments all these items.


 Return to the top 


INSUFFICIENT INFORMATION MANAGEMENT EDUCATION, (IM.4)
   Hospitals that received a score of 3, 4, or 5: 8.7%
   What the standard requires:
	   IM.4 states that hospitals are required to train and educate
	   leaders on information management principles. The intent lists
	   seven goals of this education.
   Action Points:
       Document all training sessions related to any kind of information
	   management, including inservices on QI tools, briefings on new
	   computer systems, or orientations that discuss confidentiality
	   issues.
       Have department directors identify information management train-
	   ing needs for all staff as part of their department's annual re-
	   port.
       If appropriate, consider making an IM overview part of the staff
	   orientation process for departments that use or generate informa-
	   tion.


 Return to the top 


VERBAL AND TELEPHONE ORDERS NOT AUTHENTICATED IN TIME, (IM.7.8.1)
   Hospitals  that received a score of 3, 4, or 5:  8.7%
   What the standard requires:
	   IM.7.8.1 says that medications verbally ordered are authenticated
	   by the prescribing practitioner within a time frame (considering
	   state laws) established by the medical staff.
   Action Points:
       Hospitals have the authority to differentiate between high-risk
	   and lower-risk verbal/telephone orders.	The 24-hour authentica-
	   tion time frame applies only to high-risk orders.
       Consider limiting verbal and telephone orders strictly to emer-
	   gencies.
       Make sure hospital policy is in line with applicable state laws.
       Establish a concurrent review system in which medical records or
	   nursing staff alert physicians to missing signatures.










 Return to the top 


LACK OF MEASUREMENT OF ALL JCAHO FUNCTIONS, (PI.3.4)
   Hospitals that received a score of 3, 4, or 5:  8.6%
   What the standard requires:
	   PI.3.4 states the hospital must measure the performance of all
	   JCAHO functions because those functions and their processes are
	   vital to patient outcomes. (In 1996, the JCAHO will require that
	   hospitals only measure something in two of the 11 functions, with
	   the two determined by hospital leaders.)
   Action Points:
       Even though all 11 functions will no longer have to be measured
	   (starting August 1, 1995), it's still a good idea for the quality
	   manager to keep a progress report on all improvement efforts -
	   whether they're administrative, such as medical record completion,
	   or clinical in nature, like pathways - and the functions to which
	   they relate.  It's common for one project to cover several func-
	   tions.


 Return to the top 


PATIENT ASSESSMENT DOES NOT INCLUDE IMMUNIZATION STATUS, (PE.7.3)
   Hospitals that received a score of 3, 4, or 5:  8.3%
   What the standard requires:
	   PE.7.3 requires an infant, child, or adolescent assessment or re-
	   assessment to include the patient's immunization status.
   Action Points:
       With this standard now part of the overall age-specific assess-
	   ment standard in 1996, immunization status should now be included
	   as an item on the assessment form.  This is a simple process that
	   many hospitals just forget about.


 Return to the top 


NO AUTOPSY CRITERIA, (MS.6)
   Hospitals that received a score of 3, 4, or 5:  8.2%
   What the standard requires:
	   MS.6 says the medical staff must develop criteria to be used in
	   identifying the deaths that require autopsies.
   Action Points:
       Develop a model autopsy policy and present it to the  MEC for
	   approval.  To do this, have the MEC assign a nurse, pathologist,
	   surgeon, and an internist to review the current policy and propose
	   a new one.  This must be local and/or hospital-specific.


 Return to the top 


PREANESTHESIA ASSESSMENT NOT DONE, (PE.1.8.1)
   Hospitals that received a score of 3, 4, or 5:  7.7%
   What the standard requires:
	   PE.1.8.1 requires that a preanesthesia assessment be conducted for
	   patients who are candidates for anesthesia.	Four criteria are
	   listed in the examples of implementation-evidence of a patient
	   interview, evidence of a patient physical status assessment, diag-
	   nostic test results, and the anesthesia plan of care.
   Action Points:
       Develop or revise the preanesthesia assessment form to include
	   the four criteria listed above.
       Ask the chair of the anesthesia department to consider making a
	   completed form a prerequisite to the induction of anesthesia.


 Return to the top 


HISTORY AND PHYSICAL NOT DONE WITHIN 24 HOURS, (PE.1.7.1)
   Hospitals that received a score of 3, 4, or 5:  7.4%
   What the standard requires:
		PE.1.7.1 states that the history and physical be completed within
		24 hours of admission.	The intent lists that a nursing care
		assessment also must be performed within this time frame.
   Action Points:
        As part of the concurrent medical record review done for authen-
		tication and verbal orders, have reviewers look for H&Ps and see
		if noncompliance is specific to certain individuals or depart-
		ments.
        Some hospitals use removable "flags" to allow easy identifica-
		tion of charts lacking specific information.
        Provide training and communication where needed, especially in
		areas where compliance is poor.


 Return to the top 


ADVANCE DIRECTIVES NOT OFFERED, (RI.1.2.5)
   Hospitals that received a score of 3, 4, or 5:  7.3%
   What the standard requires:
		RI.1.2.5 says the hospital must have a process to address advance
		directives, such as policies and procedures that state the right
		to formulate an advance directive and who will inform the patient
		of that right.
   Action Points:
        Develop standardized educational materials or handouts on ad-
		vance directives; most hospitals have brochures.
        Determine who performs this function.  Usually it is an admit-
		ting clerk or the nurse who performs the initial assessment.
		However, physicians are being encouraged to get more involved
		in this process.
        The 1996 intent says lack of an actual directive requires that
		the substance of a directive be documented in the patient record.
		It also says that the lack of an advance directive does not
		hamper access to care, and such cases require the hospital to
		help the patient formulate one.


 Return to the top 


INFECTION RISK REDUCTION STRATEGIES NOT IMPLEMENTED, (IC.2.3)
   Hospitals that received a score of 3, 4, or 5:  7.3%
   What the standard requires:
		IC.2.3 says the hospital must have a process to implement infec-
		tion risk reduction strategies to protect patients, employees,
		and visitors.
   Action Points:
        The JCAHO standards are pushing hospitals to have department-
		and perhaps provider-specific infection data.
        This problem usually results from hospitals not having a risk-
		reduction plan.  So if a plan does exist, document the implemen-
		tation of it and monitor the progress.


 Return to the top 


THERE IS NO PROCESS FOR INFECTION RISK REDUCTION, (IC.1)
   Hospitals that received a score of 3, 4, or 5:  6.8%
   What the standard requires:
		IC.1 says that hospitals need coordinated risk reduction pro-
		cesses to prevent infections in patients and employees.
   Action Points:
        Hospitals must have two IC plans - one describing how nosocomial
		outbreaks are dealt with, and the other explaining how the known
		risks of infection are being addressed.
        Risk reduction plans should identify high-risk departments and
		describe plans for education, intervention strategies, implemen-
		tation, measurement, and evaluation of effectiveness.
        Since the IC standards are now risk-based instead of incidence-
		based, hospitals must know the departments with the greatest
		incidence and risk.
        Review past surveillance and incidence data to pinpoint the
		departments that need closer attention.
        Develop user-friendly surveillance guidelines and forms.
        For example, if a hospital is under construction, JCAHO surveyor
		could expect to see infection control plans to prevent aspergill-
		osis-related infections.


 Return to the top 


EFFECTIVENESS OF LIFE SAFETY PLAN NOT MEASURED, (EC.1.2.5)
   Hospitals the received a score of 3, 4, or 5:  6.6%
   What the standard requires:
		EC.1.2.5 says that the hospital must have a management plan for
		life safety that includes the 10 criteria listed in the intent,
		one of which is the evaluation of effectiveness.
   Action Points:
        Although this requirement is different from the one for life
		safety performance standards, the two aim for the same thing-to
		measure improvements in life safety.  So while performance stand-
		ards will not completely satisfy the requirement to measure ef-
		fectiveness, they are good evidence that improvement occurred.
        As part of the evaluation of effectiveness, many safety commit-
		tees or life safety sub-committees create annual goals, measure
		against them, and provide an annual report for administration of
		and the board.
        Hospitals should read the intent of the standard to understand
		what the JCAHO wants the plan to address.


 Return to the top 


EQUIPMENT MAINTENANCE AND TESTING ARE NOT DONE, (EC.2.4.3)
   Hospitals the received a score of 3, 4, or 5:  6.1%
   What the standard requires:
		EC.2.4.3 say that the hospital must maintain, test, and inspect
		all medical equipment in the inventory.  There are five elements
		listed in the intent that must be considered.
   Action Points:
        Develop separate clinical and nonclinical equipment inventories,
		pulling in all equipment used for hospital patients, whether it's
		from biomed, dialysis, or radiology.  A single inventory is the
		starting point.
        Develop a prioritized PM schedule for all patient care equipment
		in the inventory, considering manufacturers' guidelines, perfor-
		mance history, and the risk to patients should failure occur.
        Except for high-risk equipment such as defibrillators, consider
		doing performance testing before electrical testing.
        Review the timeliness of inspections and report quarterly on the
		percentage of on-time inspections to the safety committee.


 Return to the top 


NUTRITIONAL ASSESSMENT NOT DONE, (PE.1.3)
   Hospitals that received a score of 3, 4, or 5:  6.0%
   What the standard requires:
		PE.1.3 requires hospitals to conduct a nutritional screening on
		all patients who are at moderate or high nutritional risk.
   Action Points:
        Have dietary propose and medical staff approve the criteria for
		identifying patient nutritional risk.
        Train staff to use criteria to identify at-risk patients and
		initiate intensive assessment.






 Return to the top 


NO "MECHANISM" FOR SPECIAL TREATMENT PROCEDURES, (TX.7)
   Hospitals the received a score of 3, 4, or 5:  5.7%
   What the standard requires:
		TX.7 says the hospital has processes to address the use of
		special treatment procedures.  This process must identify staff
		responsibilities, justify the use of the procedures, and be de-
		veloped by an multidisciplinary team.
   Action Points:
        Adapt model policies, procedures, and forms from surveyed
		hospitals.
        Pull charts for 100% concurrent review when special procedures
		are utilized.







 Return to the top 


EXCEPTIONS MADE TO SMOKING POLICY NOT AUTHORIZED, (EC.5.1)
   Hospitals that received a score of 3, 4, or 5:  5.5%
   What the standard requires:
		EC.5.1 says that a licensed independent practitioner must auth-
		orize any exception made to the no-smoking policy, which is based
		on medical staff-approved criteria.
   Action Points:
        Make Sure the medical staff-approved policy meets the intent of
		this standard.
        Make sure line staff are oriented and educated on the policy.
        Develop a standard approval process that causes physicians to
		provide adequate justification for allowing a patient to smoke.
        Review a sample of records of patients permitted to smoke to see
		if authorization is documented.





 Return to the top 


INADEQUATE P&PS FOR PRESCRIBING, ORDERING DRUGS, (TX.3.1.3)
   Hospitals that received a score of 3, 4, or 5:  5.5%
   What the standard requires:
		TX.3.1.3 says there must be policies and procedures to support
		prescribing and ordering.  The intent lists 10 elements that
		must be found in these policies and procedures.
   Action Points:
        Using the ten elements in the intent as a checklist, have the
		pharmacy and therapeutics committee do a thorough P&P review.
        Have the committee propose any needed policy revisions for
		review by the MEC.
        One are to pay close attention to is sample drugs; policies
		often disallow them, but JCAHO surveyors will find them on units.






 Return to the top 


NO CRITERIA FOR REMOVING MEDICAL STAFF OFFICERS, (MS.3.3.4.1.3)
   Hospitals that received a score of 3, 4, or 5:  5.4%
   What the standard requires:
		MS.3.3.4.1.3 states the medical staff bylaws must include a pro-
		vision for removing medical staff officers.
   Action Points:
        Medical staff bylaws should describe how voluntary or involun-
		tary removal of medical staff officers can be initiated and
		carried out.
        Have the medical executive committee develop and/or approve
		criteria for when to initiate such action.






 Return to the top 


INITIAL PATIENT SCREENING INCOMPLETE, (PE.1.1)
   Hospitals that received a score of 3, 4, or 5:  5.4%
   What the standard requires:
		PE.1.1 says an initial patient screening or assessment must in-
		clude the physical, psychological, and social status of the
		patient to determine his or her need for and type of care.
   Action Points:
        The psychological and social assessments still catch a few
		hospitals, as they're confused about whether psychiatric and
		social service consultations are required.
        Include the items listed in the standard on a structured assess-
		ment form.
        Do a periodic audit of the form and/or patient records for com-
		pliance.
        The 1996 intent suggests that hospitals ca obtain a lot of this
		assessment information from families of patients.





 Return to the top 


OPERATIVE NOTES NOT COMPLETED IMMEDIATELY AFTER SURGERY, (IM.7.4.2.2)
   Hospitals that received a score of 3, 4, or 5:  5.3%
   What the standard requires:
		IM.7.4.2.2 says that an operative note must be included in the
		patient's medical record immediately after surgery.  If there is
		a delay of more than six hours, an operative progress note must
		be documented.
   Action Points:
        Ensure that transcriptionists put a high priority on operative
		reports being turned around quickly and have a system that
		ensures they're filed in the record immediately.
        Track completion of OP notes to determine how long it takes to
		have them filed in the record and which physicians don't comply
		with the rules.  Take a QI approach to dealing with the process.
        Make sure dictation equipment is accessible to surgeons and is
		easy to use.





 Return to the top 


INADEQUATE COLLABORATION ON PI, (PI.1.1)
   Hospitals that received a score of 3, 4, or 5:  5.2%
   What the standard requires:
		PT.1.1 states that all PI activities are performed in a multi-
		disciplinary way with proper input from all departments and
		disciplines.
   Action Points:
        Have the quality manager review the hospital's roster if PI
		projects and the members of their PI teams to see if all affected
		departments were or are represented.
        Consider developing PI team selection criteria, so that PI pro-
		jects don't remain a provincial activity.
        The hospital's quality management staff should have all managers
		include in their departmental annual report any formal or infor-
		mal improvements made, identifying the medical and hospital staff
		who were involved.


 Return to the top 


THERE IS NO A NO-SMOKING POLICY, (EC.5)
   Hospitals that received a score of 3, 4, or 5:  5.2%
   What the standard requires:
		EC.5 requires hospitals to have an organization-wide no-smoking
		policy that is enforced.
   Action Points:
        Write a policy.  However, make sure the policy, or addendum to
		it, includes medical staff-approved exceptions, references any
		state laws on permissible proximity limits for smoking at entran-
		ces or near buildings, and explains the engineering controls
		(ventilation, etc.) taken in designated smoking areas.
        If exceptions to the policy are made, they need to meet the
		medical staff's criteria.  Physician-ordered exceptions should be
		documented in the patient's record.


 Return to the top 


INADEQUATE SYSTEM TO RECALL MEDICATIONS, (TX.3.2.8)
   Hospitals that received a score of 3, 4, or 5:  5.2%
   What the standard requires:
		TX.3.2.8 requires hospitals to have a process that allows for the
		retrieval and disposition of expired or recalled medications.
   Action Points:
        The challenge here is for the pharmacy to have a good system for
		communicating information to the line staff.
        All recalled medications need to be retrieved and logged by the
		pharmacy.  Many hospitals have satellite pharmacies that allow
		for better control over recalled medications.
        The pharmacy inventory system must allow pharmacists to locate
		and specify the types and dated batches of medications.











 Return to the top 


CLINICAL DEPARTMENT RECOMMENDATIONS NOT MADE, (MS.2.14.1)
   Hospitals that received a score of 3, 4, or 5:  5.0%
   What the standard requires:
		MS.2.14.1 addresses the need for recommendations from department
		chairs for a reappointment applicant or in requesting clinical
		privileges.
   Action Points:
        Develop a checklist to indicate the department director has
		received the required information about the candidate for reap-
		pointment or appointment.  However, the primary issue here has
		been that hospitals sometimes use a checklist and ignore the
		need for substantive comments by chairs.  The JCAHO said recently
		that substantive comments are required, again to prevent hospit-
		als from rubber-stamping physicians.  Surveyors will likely
		interpret this requirement differently.
        Hospitals can help get this done by staggering reappointments
		or allowing the director to appoint a designee to complete the
		work.






 Return to the top 


AGGREGATE COMPETENCY DATA NOT USED TO IDENTIFY TRENDS, (HR.3.4)
   Hospitals that received a score of 3, 4, or 5:  4.9%
   What the standard requires:
		HR.3.4 requires hospitals to gather data on staff competency to
		look for trends or patterns that may identify learning needs.
		The intent says that a report must be submitted to the governing
		board annually explaining the activities being conducted to re-
		view staff competence.
   Action Points:
        In addition to prompting hospitals to track the competency of
		their workforce, this standard also holds the board accountable
		for monitoring competency.	The JCAHO doesn't want boards to
		rubber-stamp reports.
        Hospitals should start segmenting their clinical staff into re-
		lated job categories, such as nursing, laboratory, therapists,
		etc.  Make sure each job description has measurable performance
		(competency) goals and the performance appraisal forms match
		them.
        Once this is done, a person(s) should collect data from perfor-
		mance appraisals in each job category and find out what percent-
		age of staff exceeded, met, or fell short of their goals.
        What hospitals are ultimately striving for is a competency re-
		port like the one on p.7 of the July 1995 BOJ.


 Return to the top 


INITIAL ORIENTATION NOT THOROUGH, (HR.3.2)
   Hospitals that received a score of 3, 4, or 5:  4.9%
   What the standard requires:
		HR.3.2 says that hospitals must have an orientation process for
		staff that provides job training and assesses the staff member's
		ability to perform his or her responsibilities.
   Action Points:
        Again, this is often a documentation issue, although it's not
		uncommon these days for new staff to start right away and be
		oriented days or weeks into their job.
        Make sure the hospital and department-specific orientation
		curriculum covers the landscape.
        Check that documentation is done through evaluating the new
		employees to determine that what they learned is what is re-
		quired.









 Return to the top 


END-OF-LIFE DECISIONS NOT DISCUSSED WITH PATIENTS, (RI.1.2.8)
   Hospitals that received a score of 3, 4, or 5:  4.7%
   What the standard requires:
		RI.1.2.8 addresses decisions for care at the end-of-life care.
		Processes should be in place to assist in decision-making and to
		comfort the patient.
   Action Points:
        Use an instruction sheet or outline that helps staff raise
		questions with patients about their needs and wishes in a con-
		sistant and professional manner.
        The use of this type of tool should be documented in the
		patient's chart.
        Make staff aware of the resources the hospital offers so that
		they can tell patients.








 Return to the top 


PI PROGRAM NOT ORGANIZATION-WIDE, (PI.1)
   Hospitals that received a score of 3, 4, or 5:  4.6%
   What the standard requires:
		PI.1 calls for a hospital-wide performance improvement process
		that includes design, measurement, assessment, and improvement.
   Action Points:
        Develop a PI plan that identifies how improvement priorities
		are set organization-wide and how specific projects are carried
		out.
        What is interesting about PI is that many staff and physicians
		operate from a PI mindset daily.  The challenge is finding those
		people and tracking their projects to improve.	Showing a survey-
		or a thorough inventory of improvement efforts is a good way to
		meet this standard, but be careful to portray the projects as
		collaborative and ongoing.







 Return to the top 


INADEQUATE BLOOD USE REVIEW, (PI.3.4.2.3)
   Hospitals that received a score of 3, 4, or 5:  4.0%
   What the standard requires:
		PI.3.4.2.3 says the hospital must measure the use of blood and
		blood components with attention to ordering, dispensing, admin-
		istration, and monitoring the effect on the patient.
   Action Points:
        This old favorite still catches hospitals.
        Measures should be identified for each of the four components
		in the standard.
        Staff should develop periodic reports that compare the rates for
		these measures over time.








 Return to the top 


LEADERS NOT SUFFICIENTLY EDUCATED ON PI, (LD.4.1)
   Hospitals that received a score of 3, 4, or 5:  3.5%
   What the standard requires:
		LD.4.1 says hospitals must educate their leaders on the princi-
		ples of performance improvement to better their understanding
		and improve their ability to implement programs.
   Action Points:
        If no training has been given, have all senior managers and
		middle managers read Mary Walton's book, "The Deming Management
		Method".
        At a minimum, hand out and review the intent of the PI chapter.
        Prepare a chronology of hospital PI training that shows any and
		all sessions where PI was discussed and which leaders attended.
        Make sure medical staff and board leaders are involved as well.


 Return to the top 


PLANNING DOESN'T CONSIDER PATIENT NEEDS, HOSPITAL MISSION, (LD.1.3)
   Hospitals that received a score of 3, 4, or 5:  3.5%
   What the standard requires:
		LD.1.3 states that the patient care services must be planned in
		response to patient needs and consider the organization's mission
		and the population served.
   Action Points:
        Hospitals in trouble here are located in an underinsured geo-
		graphic area, but market to insured patients and away from local
		residents.	Surveyors are likely to ask, for example, why a hos-
		pital with a poor payer mix has poured resources into an exec-
		utive wellness program.
        Add a statement of community needs and the patient population
		served as a preamble to any hospital strategic or long-term plan.
		Include any community outreach, surveys, focus groups, or other
		activities as evidence.
        Make sure planning consultants include this information in their
		final report.
        If the hospital has community representatives on the board,
		have them step forward during the leadership interview.


 Return to the top 


THERE IS NO "STAFF RIGHTS" MECHANISM, (HR.5)
   Hospitals that received a score of 3, 4, or 5:  3.0%
   What the standard requires:
		HR.5 required the hospital to have a process to address a staff
		member's request not to participate in care if it interferes with
		personal, religious, or cultural beliefs. (In 1996, this standard
		is called "Managing Staff Requests.")
   Action Points:
        Hospitals need a policy that permits staff to not participate in
		care for cultural, religious, or personal reasons.	However, the
		policy should make it clear that staff need to demonstrate such
		conviction.
        While many hospitals saw this standard as a "way out" for staff,
		the key point for hospitals is to plan for such cases so that
		care is not compromised when staff exercise this policy, so it's
		really a patient rights standard.


 Return to the top 


INADEQUATE CODE OF ETHICS, (RI.4)
   Hospitals that received a score of 3, 4, or 5:  2.7%
   What the standard requires:
		RI.4 requires the organization to have a code of ethics based on
		its mission, strategic plan, and other important documents.
   Action Points:
        Every hospital needs a code of ethics that is approved by the
		ethics committee or the equivalent and that covers everything
		in the intent of RI.4.















 Return to the top 


THERE IS NO ETHICS PROCESS FOR BUSINESS PRACTICES, (RI.4.1)
   Hospitals that received a score of 3, 4, or 5:  2.7%
   What the standard requires:
		 RI.4.1 says the hospital has a code of ethics that includes
		 marketing, admission, transfer, and discharge, and billing
		 practices.
   Action Points:
         If a hospital doesn't have a code of ethics, it obviously won't
		 meet this standard, either.
         Within the code of ethics, write a statement of ethical behav-
		 ior that summarizes the four items measured in the standard.
         Hospitals shouldn't take this lightly, since it addresses a
		 legitimate issue in the field.  Thus, whenever possible, docu-
		 ment education on and compliance with your own code of ethics.








 Return to the top 


INADEQUATE BOARD BYLAWS, (GO.2.1)
   Hospitals that received a score of 3, 4, or 5:  1.4%
   What the standard requires:
		 GO.2.1 says that the hospital's governing board must adopt by-
		 laws that contain the eight items listed in the intent.
   Action Points:
         Use the eight items in the intent to create a checklist.
         Make sure a member of the administrative team can find where
		 each item is addressed in the bylaws.













 Return to the top