JCAHO Survey – Fort Worth, TX – November 2004
36 Bed Facility

One nurse surveyor, Karen Sloan, RN
One physician surveyor, Richard Turbin, MD
Facility received one requirement for improvement (RFI) and 3 supplementals.

This hospital was surveyed in November, 2004 using the new “Shared Visions –New Pathways” patient tracer process. “Share Visions – New Pathways,” is JCAHO’s new initiative that focuses the accreditation process on care systems critical to the safety and quality of patient care. JCAHO’s Mission Statement is: “To continuously improve the safety and quality of health care provided to the public through the provision of health care accreditation and related services.” The focus I on continuous operational improvement and safe, high quality care.

For the Food & Nutrition Services Department, the focus was primarily on clinical nutrition care. The building tour is still a major part of the survey process. Kitchens remain on the scheduled tour, but the visit to this kitchen was short and brief. The surveyor reviewed and had questions about the ventilation system during the walk through.

The dietitian was present at the tracer interviews. One tracer interview focused on the most recently admitted TPN patient. Questions were:

• What is your input for patients on TPN?
• How do you determine which patients need to be assessed?
• How do you obtain referrals from nursing?
• What are the criteria for referrals?
• Can you write basic orders for nutrition supplements?
• How do you and the pharmacist work together to get the most appropriate TPN order?
• Do you run an albumin report?

Surveyors reviewed tracer medical record progress notes for communication between the medical team. In the tracer interview, team members were asked to explain their entries as well as the purpose for the entry. Surveyors looked for notes in the medical record regarding timing of nutrition assessment and monitoring of nutrition care.

During this survey, kitchen employees were not asked questions, including any Patient Safety Goal questions. These questions were asked in the tracer interviews and tracer process. Evidence for following safety rules was through observations and medical record documentation.

The Food Service Director was pleased with this new survey process as well as the hospital outcome. Their plan of action for the one RFI will be submitted to JCAHO within 90-days from this November survey via the Internet. Note that the plan and implementation must be completed before submission. If the RFI requires monitoring, compliance must be at least @ 90% to the standard within that 90-day period. Supplements must be addressed, but do not have to be reported to JCAHO.

We at Destination 10 Headquarters thank this food service director for an interesting and helpful anecdotal recap of their successful JCAHO experience.

Don Miller, R.D., C.E.C.
Success Coach

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