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Nurses who volunteer for JCAHO educational activities
also receive bonus points on their performance appraisals
as part of a new clinical ladder system, said Uttley,
who chairs the hospital's Nursing Assembly, a decision-making
body for nursing that has 19 committees and councils
and covers all procedures and protocols. The groups
are being brought up to speed on changes in JCAHO's
assessments and standards. The products committee, for
example, might focus on safety standards related to
free-flow pumps or the dispensing of medications.
"We're also focusing on the environment of care
and are starting to see some positive results in a short
period of time," Uttley said. "We expect people
to do environmental care rounds twice a month-tracking
and trending-to make sure any issues are dealt with.
For example, if there's a biomed or engineering issue
that nurses repeatedly are asking to be taken care of,
we have a system to follow through and resolve the issue."
A key reason for the VA hospital in Los Angeles to
volunteer for unannounced surveys was to get a jump
on integrating JCAHO's new policies and procedures into
the accreditation process, said Theresa Osborn, MSN,
RN, quality management officer for the VA Desert Pacific
Healthcare Network.
"It forces us to truly do a deep assessment, because
if we're not in total compliance, we must come up with
a plan with timelines and a real course of action,"
Osborn said. "This can be very beneficial to us."
Donna Beiter, MSN, RN, nurse executive of the VA Greater
Los Angeles Healthcare System, said the VA Healthcare
System has established a number of quality benchmarks
in the areas of patient safety, computerized patient
records and barcoding.
"This pilot is the next step for us. It's not
about JCAHO as much as it is about continuous readiness
and quality patient care, and that's why we're very
committed to it."
However, Ann Kobs, MS, RN, a former surveyor who helped
develop standards and trained survey teams, remains
skeptical as to whether unannounced surveys will ever
become a permanent JCAHO policy. "I support unannounced
surveys 100 percent, but 2006 is a long way off, and
the political forces against the policy change are strong."
Kobs, who spent 10 years with JCAHO and now runs her
own health care consulting business, said the JCAHO
board is composed of members of major hospital and physician
organizations that don't want to be caught by surprise
inspections that may find areas that need improvement.
"These are organizations that have fought against
unannounced surveys for years," she said.
Other surveyors who have left JCAHO share Kobs' skepticism,
she said. "There are a lot of us who believe the
unannounced surveys are a great idea, but will be a
tough nut to crack."
JCAHO's Murphy-Knoll said hospitals no longer will
receive an advance agenda from the survey team. Instead,
surveyors will rely on what is termed a priority focus
process (PFP) that is directed to organization-specific,
critical patient care processes and systems, instead
of rote assessment of standards compliance.
Much of the PFP information will be gathered before
the on-site survey and will be evaluated for compliance
to selected standards during the analysis of a particular
patient's care-a process known as tracer methodology.
For example, if PFP data identified a health care organization
as having a large number of geriatric patients, a critical
focus would be on medication use. The surveyor would
ask for active patient files that involve multiple medications
and use tracer methodology to examine prescribing, dispensing
and monitoring procedures.
If problems are identified during a survey, the organization
will have 30 days to devise a remedial plan of action
and receive an "accredited" status at that
time. JCAHO also has made other changes to streamline
the accreditation process for about 17,000 health care
organizations, and it will take some time to get the
kinks out.
"All these steps are being tied together and will
make it possible to go to unannounced surveys,"
Murphy-Knoll said. "They [unannounced surveys]
make sense. There's no need to ramp up, and they promote
continuous standards compliance, which is what we all
want. It makes the accreditation process much more credible
to the public and patients."
The VA's Slaughter said the tracing methodology will
give surveyors a much more thorough picture of how a
patient is treated than they would have received in
the past by questioning the nurses and staff. "The
only anxiety nurses will have now is from having someone
they don't know observing their practice."
Contact John Leighty at johnsan@aol.com
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