JCAHO Inspection – Columbia, South Carolina
December 2002 – Acute Care Facility
Licensed # of Beds: 292/Avg. Census: 218
Score: 96 – Length of Inspection 3 days

The Food Service Department tour was brief in this case. The Administrator Inspector spent all of his time with the staff and gathered them in the cafeteria dining area. His emphasis was on safety in the kitchen and hospital. 

Questions asked of the staff included:
-Where are the fire extinguishers?
-Where is the fire pull?
-Where are the exit doors?
-Where is your MSDS information?
Time was spent on relating fire and rescue stories with the staff. 

A staff member was asked what they would do if there was a fire on the 8th floor?
The inspector was looking for an answer regarding “evacuation” – this good-natured employee wanted to go to the 8th floor to rescue the patient but eventually said that “evacuation” was necessary! 

The tour was anti-climatic per this Food Service Director – there was little investigation of the kitchen in the usual fashion.

The nurse inspector spent a lot of time interviewing hospital staff on age competency procedures and documentation for proof of staff education.

Patient Restraints and Advance directives were a large focus.

Patient Care Interviews were still conducted on each nursing unit –these are eventually getting phased out of future tours per this inspection group.
On the nursing units the Dietitians’ were occasionally asked a question regarding why a patient had been seen? Whether nutrient–drug education had taken place, how the 24 hour screening process worked etc. and was satisfied with the answers given and did not delve further.

An interesting concept that is appearing to surface from recent interviews is that the inspector is asking the RD why they are seeing patients not found at nutritional risk? They want a clear delineation between levels of low, moderate and high risk and are not impressed with RDs’ spending time on patients not at risk –overkill is not impressing them. They are more interested in best use of the clinician’s time and appropriate prioritization of patient risk and care. In fact a statement was made that a Type 1 Citation could be the result of inappropriate use of the clinician’s time in some cases if extreme enough. The RD gave a good reason for this patient to be seen due to other existing risk factors (socio-economic, etc.). In this case the inspector felt the visit was logical and justified and approved of it.

A lot of time was spent in Closed Record Review at this facility – of which the Chief Dietitian attended but was not asked questions. She felt it was more of a “token” interdisciplinary representation for the process.

The Hospital Directors Interview held by this Administrator proved to be most precarious, per this FSD. He asked the group to picture the scenario of being at a hospital in Alaska in the late afternoon and to visualize a polar bear walking by and triggering the automatic front doors of this hospital which enables the bear to enter the hospital………..”What would you do?” While the inspector allowed the team to ponder this question he went on to tell about the wonders of both Alaska and Germany and stressed the need for all to see 3 wonders in their lifetime: the Great Wall, the German concentration camps, and Alaska…….
….after coming full circle the Administrator gave the answer to the polar bear question. There were 3 action items that should have been done: 1. to call animal control 2. to shoot the bear with drug darts 3. to remove the animal. 

In wrapping up the inspection the inspectors stressed that the future tours of JCAHO would take on a totally different focus, which has been the buzz for awhile now. The inspector stated that the interviews and building tours would be “watered down” and instead the emphasis would be a day in the life of a patient. A typical patient’s journey from admitting to all of the various ancillary departments (radiology, lab, meal experiences etc.) would be simulated and reviewed to assess the type of care given by the hospital. Another confirmation that the tours will be focused on true operational improvement versus short-sighted, quick fixes geared to “the visit.”

We at Destination 10 Headquarters thank this D10 client for this interesting and helpful anecdotal recap of their successful JCAHO experience.

Don Miller, R.D., C.E.C.
Nancy Yezzi, R.D., L.D.
Bill Klein, C.I.C.
Success Coaches

Don Miller and Associates
346 Crestview Drive
Bonita, CA 91902
(619) 656-2100 PST
(619) 656-1321 fax
chefdon@cox.net
http://www.chefdon.com