Results of a recent JCAHO Survey
Lincoln, Nebraska
February 4 – 8, 2002

Surveyors:
Larry Moss, Nurse                                                           E. Ritty, Mental Health
Allen Humble, Administrator                                             Mohammad Ansari, MD
Robert Alserver, Ambulatory                                             William Lundberg, Trainee

A Medical Center with 2 locations
East Site Staffed Beds to Include TCU: 284 (Budget 2002)
West Site Staffed Beds to Include TCU: 240 (Budget 2002)

Anecdotal notes: 
Some of their comments were: the food was excellent, hospitality was excellent. Very impressed with the honesty of the staff, they did not try to hide things, showed how we have tried to improve. Enjoyed interaction with employees, very good at what you do.

Main Kitchen Survey:
The Administrator spent less than 10 minutes with the Cooks & Production staff in the kitchen and the focus was fire suppression.

The cooks did a great job answering his fire suppression and hood system questions. The surveyor asked how a grease fire was suppressed? He wanted to know details of the system such as was powder dropped? How is the Fire Department notified? He had the employees explain the mechanics of hood suppression. The surveyor also asked to see the last inspection report from the local health department – he reviewed it without comment.

Supplemental Citation received:
This facility received the following supplemental citation regarding a nutrition issue. Supplemental Citations require that the facility deal with the issues, but no written report is required.

1. Two patients determined to be at nutritional risk and consult not done, questioned their policy of having 48 hours to complete the consult. The surveyor felt that that time span was too long. The facility will be collecting data on how many patients are missed due to patients leaving before the completion of the consult. 

Notes from Clinical dietitians regarding questions asked during patient care area interviews

Dietitian #1 participated in oncology, critical care and progressive care. The nurse surveyor asked the most nutrition specific questions in the CCU and PCU.

1. What is your role on this unit? (And he wanted very specific answers)

2. Followed up with questions regarding procedures, such as nourishment delivery to provide smaller meals during the day.

3. Asked what was missing from our nursing database. (Answer: Geriatric surgery and was pleased that it was one of our risk factors even though it wasn't on the screen).

4. Asked about our policy regarding the nutritional consults.

5. Also, asked the group why "nutrition was getting picked on?" and replied that nutrition plays such a role in patient care and needs to be focused on. Also stated, "Dietitians all over are getting the devil beat out of them”.

Dietitian # 2 was asked about how a patient is referred to them, and what happens after the initial assessment. The surveyor was referring to follow-up and wanting to make sure that the patient was being seen between the time that another assessment would happen on the 5th day. The surveyor also wanted to know how other patients would be seen by the dietitian other than the screening criteria done on initial nursing assessment.

Labor and Delivery, Post Partum: The only question that was directly asked of the dietitian was if she was involved with all lactating mothers. Explained that the unit had lactation consultants and that she (RD) was available on a consult basis.

General Surgical unit: Group question - asked if any of the team members were involved in a process improvement. Explained our 6-month, on-going PI with the nutrition screen on the nursing assessment. Improved to 89% of completing the nutrition section. 

Senior RD on staff
3SE/3SW Child and Adolescent Psychiatric Services (Inpatient)
Nurse Surveyor

The surveyor had all team members go around the room and describe what their role was on the unit. When the Dietitian identified herself – he asked if she was assigned to the area, which she responded to affirmatively, and he said “ oh good – we’ll have lots to talk about – with all the nutritional problems teenagers have”.

The surveyor focused on the timelines for assessments overall – not specific to anyone, but talked about the fact that their assessments and input done within 48 hours – whether it be nutrition or social services, was too long for the current length of stay. 

Rehab/Adolescent Unit: Regarding 48-hour timeline to see patients after initial screening:

One of the youth family specialists (an M.D.) answered by saying that the initial hours are not appropriate for us to set real goals for the patients other than safety because they are having their lives disrupted, have been taken from their homes and a lot of times need some time to start to trust the staff. 

The Dr. also provided the surveyor with the concept that most of the inpatients that are on the unit either move on to the partial care area or the staff works with the community resources and that there is no static assessment because it’s a whole continuum of care for the patient. The surveyor was pleased with this. 

Nutrition Specific: The nurse surveyor wanted to know how the dietitians’ were able to meet the needs of the patients nutritionally – the R.D. described that the adolescents are able to choose their own menus, that they have optional write-in items to help meet preferences and that they have worked with the unit (both child and adolescent) to provide 3 between meal snacks every day and that it has worked well for those who have lost their appetite with depression and feel overwhelmed with the larger trays. The child unit gets a predetermined age appropriate house diet and everyone gets the same thing and the surveyor also was fine with this.

The chart that he pulled was a teenager with major depression and an eating disorder not otherwise specified with purging. The nurse showed him where the different assessments were and where the education was documented and as she pointed out the nutrition note the surveyor just shook his head and said “their (eating disorder) eating behaviors are just terrible” and that was all.

4SW/Oncology Inpatient
Administrator Surveyor

The surveyor had all team members meet together and he did not go over any patient chart with the whole team. When he was through with the team, he had the oncology coordinator and the charge nurse go through a chart review with him.
This surveyor had no specific questions regarding nutrition.

The administrator was most interested in what kind of input staff has had regarding the expansion project, as well as input from the physicians ( a hospital oncologist was present for the survey). 

The surveyor also wanted to know how staff felt about what kind of job Human Resources was doing in terms of recruiting competent people to work here. 

He asked: how we would rate them on a scale of 1-10?

What happens when the census goes up? What happens when an oncology certified nurse gets pulled to another area? Who is able to cover for who, etc.?

He wanted to know from the manager what things were being done to help prevent burnout with the staff that might end up working overtime or extra. He wanted to know how patients respond to the physicians and vice versa – the surveyor asked one of the Oncologist’s why he chose to send patients there? He also asked if there was a new board and changes were made –what would patients want to see kept the same? 

The surveyor asked the Oncologist about how he felt the staff was competency wise – he answered that there is always (in terms of nursing) someone here who knows the ropes, so that even if there is new staff there is always one person he can go to that will be able to help direct him and take care of what needs to be done. The Oncologist stated that he doesn’t hear any bad complaints about the dietitian or the physical therapist – and he sees that as a good thing – he stated that it is natural that he would hear the most compliments about the nursing staff because of the more intimate nature an oncology nurse has with her patient.

The last thing the administrator asked the team was about positive changes that have been done for patient care – the oncology coordinator gave him several examples, which he was pleased with. The R.D. got the feeling that the surveyor was very pleased to see that there was a physician who actually attended the meeting.

5NW/Critical Care – Intensive Care
Physician Surveyor

The physician met with all team members first (and then had an extremely brief look at a chart afterwards with no comments). The surveyor had everyone go around the room and explain their role. He stated that he wanted to use this time as an opportunity to educate all of them on something that needed to be worked on, because he had already seen that there was a need for it in the facility. He asked certain individuals – and wouldn’t let pharmacy answer- about adverse drug reactions – several of the attendees gave examples of what they might see that might make them suspect an adverse drug reaction (ADR). What the surveyor was looking for was what the hospital definition was, what the different levels were,etc. He informed the team of what the hospital percentage for reporting adverse drug reactions was and stated that it was not high enough and therefore there was under reporting being done. The surveyor wanted to make sure that the team utilized pharmacy that if there was a suspected ADR but that pharmacy should be the one to determine if it was or was not an ADR

Specific to nutrition the surveyor asked the Dietitian if she was assigned to the unit, and he was pleased that she was. He asked if she saw everyone on the unit, and the Dietitian responded “yes”, and then he asked “even if they don’t trigger out on the screen?” The R.D. said “yes” and he said “good!” – with a smile.

The surveyor asked some things in regards to respiratory and social services and then he came back to the R.D. and asked “ tell me about the use of TPN in your unit?” The R.D. said that it had been trending down, and that the they are trying to use enteral feedings whenever possible, and he said good. The surveyor then wanted to know “how do you know that it (TPN) is being used appropriately?” 

The Dietitian stumbled for a bit because they hadn’t actually tracked this about TPN or done any QI studies but then said that the RD works with nursing and the physician and Pharmacy and that they get lists from Pharmacy and they review it. The surveyor still pushed for the how, and the R.D. said that there is a standard order form that can be used. The surveyor then asked, “what does it follow? ” A staff physician then explained the process of how the standard order form must go through pharmacy and therapeutics committee, etc. The surveyor pressed on and asked the R.D. “but what standard do you hold it up against?” and then the light bulb went on and the R.D. said that they used the ASPEN guidelines for our standards of care for nutrition support and he smiled and said “great!” – but then he said “you are using the guidelines – how do you make sure the physicians know that you use them and that they should be using them? ”. The R.D. gave the surveyor the example of a couple of months ago, as part of trauma rounds. The dietitian had identified an education need for some of the new trauma physicians in that area, and added that she had reviewed the ASPEN core curriculum and provided guidelines and references for the use of nutrition support in Trauma and sending these out to all of the Trauma physicians and the pulmonologists - and he nodded and said “good”.

5SE/5SW- Affective Disorders and Adult Psychiatric Services Inpatient
Nurse Surveyor

This part of the report reflects the last half of the meeting when the surveyor reviewed a chart. The surveyor had the charge nurse explain how she used different forms and the assessments and he asked her about nutrition. The nurse stated that if the patient triggered out that they send a consult and that sometimes the nurses would help the patient’s with basic nutrition needs such as ordering snacks for them, providing them with certain videos/education packets that are located on affective disorders for the patients to use and that they consult the dietitian when there are specific nutritional needs or concerns. 

Then the surveyor asked about the group schedule and different groups and he asked the R.D. to explain what the nutrition group was. The dietitian described it to him and he said “ now that sounds like a really wonderful group that would be very beneficial for all patients.” “But if I’m admitted on Friday and leave on Monday I don’t get to go to nutrition group (the group was meeting once a week on Thursday). The R.D. explained that the group was educational, but that all patients would have the opportunity to meet with a dietitian if they wanted and that they would be available any day of the week to do assessment or education. The surveyor was ok with this but still felt like the patient would be missing something – then he went on to point out other discrepancies about weekend groups and that basically, he just didn’t think it was balanced enough, however, when he summarized before he took a walking tour of the unit, he said that everything looked fine. 

Care of the Patient Interview
Nurse, Administrator and Physician Surveyor

Physician asked, “How do you know that patients get the correct diet?” A variety of answers were given from staff such as trays have menu cards that list name, room, diet type etc., and nurses check the tray against the diet list that is provided. What he was looking for was “meal rounds” or something of that nature. The surveyor said that they did not have a be a daily thing, but maybe quarterly where you would compare the diet order in the chart to what is ordered for the patient and what the patient actually received. He was recently in the hospital and received several wrong trays (he didn’t complain, said the food was good), but diet given was wrong.

Also again had a long discussion asking for the definition of Adverse Drug Reactions which in the end to this R.D. meant what they wanted to hear was ADR meant “any” reaction to a medication whether it is expected or not should be reported and that Pharmacy should determine if it is adverse or not. The surveyor repeated that the reported rate was too low for a hospital of this size and employees weren’t reporting ADR’s.

This was a very thorough reporting job from this facility. We are very grateful for their input – keep up the great work!

From the Destination 10 Success Coaches:

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