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JCAHO
Inspection – St. Augustine, FLA
Acute Care Facility – April 2003
Surveyors
Kathlyn Wade-R.N.
Allen Humble-Administrator
Dr. Potter
Facility Size: 260 Beds
Score 93
1. The Administrator was the surveyor for
the main kitchen and he spent a good 30 minutes talking to the Director,
Supervisors and staff and particularly to the Cooks. When touring the
kitchen he immediately wanted to know who the cooks were and asked them
about the fire suppression system. He did not want to know RACE. He asked
how the system worked, did they have to activate it and if so, where? What
side of the hood did each release control? Did the system automatically
shut off the gas and electric or did the employee need to? Did the system
call in the alarm or did the employee need to? He asked where the fire
extinguishers were located? He also asked how long an employee would fight
a fire before leaving? (Ans.”I’d try and use the fire extinguisher but if
it didn’t help matters, I’d evacuate.” –looking for something close to
this response).
2. The surveyor also asked what
pre-employment and daily screening measures were in place for ensuring
that staff is not sick or has a communicable disease. He was satisfied
that this site used the pre-employment physical for TB and Hepatitis. This
facility utilizes a checklist of items that the supervisors check for each
day on each shift ( cuts, illness, etc). He suggested that the department
institute either formally or informally checking with our staff if any
family members or friends are ill and what we might be looking for (i.e.
SARS)?
3. The surveyor asked about the facility’s
diet office procedures. He liked that this facility
used the computer system and got real time info about diet orders. The
surveyor also liked that this diet office runs a hard copy of all diets
twice per day (diet roster). They always like a “checks and balances type
system” in place.
4. When in HR, the surveyor paid close
attention to employee evaluations. He wanted to see that anything less
than meets basic standards had an action plan with follow up,
particularly if it involved patient safety. He included food-handling
procedures in patient safety for food service workers. He was not
impressed if an employee had a “meets standards” for customer service but
an “opportunity for improvement” in their sanitation or safety practices.
The surveyor recommended a hospital-wide revamping of their evaluation
tool in the areas of standards for essential competencies and wanted the
level of competency raised from: 1) meets basic expectations 2)
opportunity for improvement 3) needs improvement to a higher level of
standard such as: 1) Exceeds expectations 2) Meets basic expectations
3) opportunity for improvement. Changes are underway in this area and
in standardizing the guidelines for the action plan and follow-up,
once an employee is deemed as having an “opportunity for improvement.”
Major emphasis was put on the effective follow-up for this area.
This facility plans to initiate quarterly
peer reviews of each other’s departments to be sure each discipline
correctly documents and follows through with all employee action plans.
5. Clinical unit meetings were all held in
a group format with no special, discriminating focus on nutrition that was
out of the ordinary. One item noted was that the nurse surveyor did not
see that a hospice chart was a “DNR” and questioned why there hadn’t been
more aggressive follow-up. Once explained by the Dietitian, the surveyor
had no issue with this care.
Future visits and the focus for 2004 :
During the visit the direction that future
JCAHO site visits will take came up. It was noted that surveyors said that
the visits would be shorter, more frequent, and unannounced. It was
mentioned that some type of problem about the facility’s environment could
trigger a visit. Once a recommendation was made at the site, the facility
would have the normal time to correct it but that it would not be uncommon
to get another follow-up visit within 90 days of the correction. Reference
to the type of activities we can expect during future site visits would be
a “ day in the life of a patient” by following tracer methodology.
(Tracer methodology defined by JCAHO as “ a
way of analyzing the organization’s systems.”) The surveyors will identify
critical focus areas by following active patients through the entire
healthcare processing sequence that they would experience.
We will report more on JCAHO changes in
future Destination 10 Success Hints and Tips, so 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
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