Don Miller & Associates - Hospital Room Service and Healthcare Food Service Consulting

JCAHO Survey – Houston, Tx – Summer 2003
Large Multi-Facility Acute Care Health System
Part 1

This survey was several months long in duration due to the fact that there were numerous facilities (10) to inspect. At the time of this printing at least seven of the sites had successfully completed their inspections with scores ranging in the low to high 90’s. Kudos to all involved in your diligent preparation and subsequent success in this endeavor.

Surveyors:
Due to the number of facilities involved the team of surveyors varied from survey to survey but included the following in various combinations:

SHIRLEY FRANCISCO R.N.
CAROLYN GILLESPIE R.N.
JOHN COMSTOCK M.D
MARY E. GILBERT REASE, R.N., M.S.
ALAN W. BLACK, M.D.
FRANK H. GILLIAM
PAUL SHETLER,M.D.
WALTER DIGGS

We will present a variety of sample questions and key areas of concentration. Patient safety was a big focus throughout the entire process in all areas, beyond Nutrition Services.

Chart Review:

Surveyor requested staff nurse to answer questions.
What is the medical record number of this patient?
What is the admitting diagnosis of this patient?
What is the date of admission?
How did the patient arrive to the hospital?
What time did they arrive in ER?
Is there a triage time?

Questions re: ER:

Did they put the patient on medication?
Any pain medication administered/documented?
How long before the patient was admitted to ICU?

Questions re: ICU:

Is there an admission sheet that is filled out by the nurse?
Could the patient answer all the questions?
Did they bring a copy of the advanced directive?
Where is the nutritional screening?
Explain when Food & Nutrition intervenes on diet.
If patient had regular diet but had a decubitus, how would nurse know to send for screening?
How do you find the patients outside of the screening?
How long was patient in ICU?
Where would the transfer sheet to floor be?
How would you know what medications the patient transferred to floor with?
Where are the medication orders written out?
How does doctor transfer medication orders from ICU to floor?
What is the policy?
Was there another assessment when patient arrived to floor?
Is care plan continued from ICU?
Is there a care plan that was started in ICU?
Where are the goals? How do you do the care plan?
Were any further problems identified when patient arrived to floor?
Any problems with pain, constipation, skin integrity?
Was there a dietary assessment done? Where is it in the chart? Print out copy from computer.
What is the policy of following up with dietary assessment?
Show me the educational assessment and teaching.
Is there cultural and religious portion?
Is dietary included on education?
What is the policy of dietician vs. diet technician to observe patient based on skin breakdown?
Where is nutrition documented in care plan? Why is it not written as a goal on care plan?
Show me the typed nutrition assessment.
Has patient been educated on her diet?
Was patient put on TPN?

Standing in front of the Patient ‘White Board’ (erasable, communication board in patient’s room).

Tell me about this in relation to patient confidentiality. Shirley seemed impressed w/our methodology, i.e., patient’s last name, and first three letters of MD’s last name. CNO explained that this method was in compliance w/HIPAA.

Nutrition Questions During Patient Chart Review Session

L&D

1. How do you know when an L&D patient is at increased nutritional risk?

2. Give me an example of a patient in which you will intervene.

3. Discuss how your department meets any of the patient safety goals?

SNF
1. After reviewing two charts, I was not able to find the Nutrition Note in one of them. Where is the Nutrition Note for ______ patient?

ICU
1. Do you feed ICU patients?
2. Do you assess all ICU patients?
3. How do you determine if the patient’s diet is correct?
4. Do you have other means of determining which patients are at increased nutrition risk?
5. Does the entire team document on a common ‘multidisciplinary’ care plan area of the chart? (Key recurrent question and concern throughout the entire process at each facility).
6. Who maintains the unit’s patient refrigerator?

TOUR of Food Services (Carolyn Gillespie R.N,)

1. How much inventory did we have on hand in case of an emergency?
2. How is food issued out of the Freezer?
3. How do you thaw foods?
4. Show me your storeroom, freezer and dish room.
5. As we were walking, CG asked Food Service Director to clarify the nutritional assessment process. Asked several questions on specific charts and what she saw or did not see and why that might be. We had Chinese patients that did not speak English and asked how we assess and communicate with them?
6. How does Food and Nutrition Services interact with Speech therapy?
7. Show me your dish machine temperature records and how often are you recording these?
8. Who delivers and picks up the trays from rooms?

More of the various Food Service facility tours (main kitchen) will be outlined in a second JCAHO Hint & Tips –Houston 2003 Part II in the next few weeks………stay tuned.

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