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Recent JCAHO Survey/Pediatric
Hospital
Greetings to all on the D10 e-mail network.
Wanted to send a Hints & Tips newsletter regarding another client
JCAHO survey. This one was performed between July 24th
and July 27th, 2001 in Chicago, Illinois at a 250 bed pediatric hospital.
Our hope is that you will find new insight
and tips in each Hints & Tips regarding this topic so that you can be
as successful as possible in passing your JCAHO inspection.
Surveyor Profiles
Physician: Elise Rosenblatt M.D.
Nurse: Karen Szymanski R.N.
Administrator: Jerry Dykman
The administrator, Jerry Dykman, was the
person that performed the physical inspection of this nutrition services
department. Mr. Dykman is a retired naval officer that was amiable for the
most part. He demonstrated that he was a sport by accepting and wearing
the hospital’s logoed baseball cap given to him upon arriving for
inspection. Mr.Dykman arrived after the meal was served and tray line was
over. He did observe the hostess program in action by shadowing one of the
hostess’s and also interviewed a patient’s family about the nutrition
services rendered.
For the record, Mr.Dykman made a 4:00 a.m.
visit to the hospital facility and went to Radiology and the Laboratory
Departments. On another day he also parked his car at 5:00 a.m. in the
parking lot and observed the valet service, loading dock and security
services and practices. This creative Food Service Director went directly
to the car and served him coffee and danish!
Basic Information
What did the surveyor look for?
1. The surveyor went over every single
piece of equipment physically with his hands looking for dirt, dust and
grease. He touched all of the legs and counter edges too.
2. The surveyor went into the coolers,
looked at vents for dust and grime, checked food products for labeling and
dating etc..
3. The surveyor questioned the practice of
dating all #10 cans, as required by HCFA (new name Centers for Medicare
and Medicaid Services ). He appeared to feel it was not needed.
4. The surveyor reviewed quantity
production recipes and liked the way that this director incorporated HACCP
standards into them.
5. The surveyor reviewed the department’s
HACCP plans (of which this department had 5 of) and requested to look at
the patient menu also. He did not request a nutrient analysis, but did
look to see if an R.D. had reviewed it and signed off on it.
6. At a later clinical team meeting, the
R.N. surveyor requested to see the menu nutrient analysis, which was
provided by the R.D..
7. This Food Service Director along with
all departments in the hospital, displayed their CQI programs in
storyboard form and they were well accepted.
8. Mr. Dykman asked 2 employees’
questions as follow: “ where is the automatic shut-off valve for the
fire extinguishing system”, and “ where is the nearest fire pull?”
9. The Maintenance Department was present
at the entire interview. All equipment had up to date preventative
maintenance stickers on it.
10. The surveyor walked over to the branded
food court to an individually operated McDonald’s counter and asked the
employee about the fire evacuation route and asked the owner to produce an
employee file. He was looking to see if these contracted employees
underwent the same hospital and department orientation that the food
service employees received.
11. The nurse surveyor asked a clinical
dietitian about her department’s Hostess program and did not like the
fact that the clinician appeared unaware of it. The director assisted in
answering the question to the nurse’s satisfaction.
12. The nurse surveyor reviewed clinical
documentation.
13. The surveyor inquired about a
24-year-old patient in this pediatric hospital and was particularly
interested in whether accomodations were made because of his age. The
director assured the surveyor that serving sizes were increased to
accommodate adult nutrient requirements. (age competency)
14. Mr.Dykman concluded his tour with the
comment that “ this is a very well run kitchen.”
Kudos to this client from Don Miller and
Associates and thanks for sharing this valuable information.
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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