JCAHO Survey
October 2001
Central Ohio Facility

Surveyors: Bonnie Borchman RN, Dr. Rossi – Anesthesiologist, Ken Hollenbaugh-Administrator.

Trivia: This team showed up most mornings by 6:00 a.m. and also came in during the evening shift on walk-throughs @ 7:30 p.m.. The physician requested rose tea (never touched it) and bottled water. The administrator “knows his stuff”, and “isn’t into BS answers” per this FSD. Being genuine and listening to his feedback along with putting it into action are 2 items valued by Mr. Hollenbaugh.

Score: This hospital scored an 88, verifying the most current information that we’ve presented that scores are significantly lower around the country. There were no type I’s for this food service department.

This inspector did not ask any questions of the general food service staff (excluding dietitians). The actual walk-through of the FS department lasted about 2-5 minutes and only looked in-depth at one walk-in cooler with no significant findings or comments. He stopped at a combined hand sink/eye-wash station and mentioned to the director to have only cold running water at this particular sink.

Human Resources Interview

• Pulled an RD file by name and keyed in on competencies, age specifics, evidence of orientation/training, licensure, etc.

Meeting of Selected Department Heads – The Food Service Director attended

• Two specific questions were asked relating to food service. The inspector wanted to know whether the census or the budget drives staffing? He also asked if there was cross-coverage between hospitals in the system? (See answer under Food Service Director’s interview below).

Food Service Director’s Interview:

• The Director had prepared a process improvement storyboard, which was never looked at.
  

• The Director had to explain how or if flex staffing was utilized in this facility. This hospital’s method of food service delivery is cook/serve via carts operating out of galley’s on the various patient units. The director had to explain that certain essential duties and processes were necessary to this style of food service whether there were 100 or 250 patients.
  

• In answer to the cross-coverage question between the 3 sister hospitals, the FSD explained that clinical dietitians were flexed between facilities for staff/vacation relief.
  

• Dish machine temperatures were a problem only in the area of documentation. The actual documentation sheet had the “final rinse temperature” column switched with the “auxiliary rinse” column. The actual temps. were appropriate according to code. The FSD had the documentation sheet corrected and also brought in the dish machine manufacturer’s rep. to verify their accuracy – this prompt response resulted in 0 deficiencies. 

Patient Care Interview:

• Much of the time was focused on pharmacy issues.
  

• Specific nutrition questions centered around performance indicators used for QI monitoring.
  

• Overview of Nutrition Care Subcommittee and involvement in P & T committee Questioned various disciplines about decision-making processes – to ensure interdisciplinary and clinician’s involvement in process improvements.

Mother Baby Unit – RN

• Focused on triggers for nutrition assessment. They wanted a clear differentiation between levels of risk for moms and babies. Is the risk immediate or does the mother need education? A specific maternity policy was developed to clarify this.
  

• Asked for explanation of dietetic technician’s role. Why do they perform assessments and handle consults?
  

• Inquired about weekend and holiday coverage. When a DT is staffed with an RD on call, will the RD come in to do assessments of high risk patients? They were satisfied with a review and recommendations done via the phone with a full written assessment done on the next working day, in the morning when it occurs on a weekend.

Med Surg Units

• On every unit an explanation of staffing adjustments for patient census were asked of RD’s. How weekend and holidays are covered was routinely inquired of RD’s.
  

• The charts pulled for review were typically a usual diagnosis for the unit. Also pulled fattest chart, nutrition support, pediatric.
  

• Inquired about routine follow-up with nutrition support. Looked for integration of care. Is assessment done with change of status. Are doctors listening to recommendations?
  

• Looked at nutrition screening triggers. Asked if high-risk patients were referred to dietitians. Asked if they were seen within 24 hours. The surveyors emphasized that they did not expect or want to see dietitians spending time with low nutrition risk patients or in re-screening patients to identify the high risk referrals if nursing wasn’t very effective in giving the needed notification.
  

• Asked if herb and supplement use were identified and addressed.
  

• Asked about resources for eating disorders in the community.
  

• Inquired about food / drug policy. Key meds were addressed, etc..
  

• Inquired about unit/department specific performance improvement activities.
  

• Looked for interdisciplinary involvement and patient outcome changes not just process audits.
  

• Units that were not on the schedule received a surprise review by a surveyor and still had a comprehensive focus interview.
  

• Spent time interviewing each RD about time frames for assessments, and consults.

Ambulatory Care (Cancer Care Center)

• The RD gave an overview of the nutrition screening tool initiated by nursing and flow of referrals.

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
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