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Continual readiness

by: LAWRENCE M. SHUER

Next spring we can expect to have another combined accreditation and licensure survey by the Joint Commission on Accreditation of Healthcare Organizations and the state's Department of Health Services. In an effort to improve our results, we have been working toward a state of "continual readiness" for these surveys rather than rushing to prepare at the last minute. After all, the purpose of these accreditation agencies is to make sure we maintain certain standards all the time and not just during the surveys.

An apt metaphor for this effort is that of preparing for an exam. When you "cram" for a test, as we have tended to do for these surveys, it generates considerable stress and much of the material is forgotten soon after the test. But if we truly learn the appropriate policies, we will be more fully prepared to have a survey at any time, not just during a preannounced visit.

In fact, this is precisely the direction in which JCAHO and the Department of Health Services are moving. After 2004, these entities will conduct unannounced visits as their method of checking on hospitals.

In preparation for our next survey, you may be asked to participate in some mock surveys that are meant to help point out our weaknesses and allow us to implement changes. Our goal is to identify any potential areas of concern before the real JCAHO visit. It's important to note that these visits have become much more like actual inspections to see if we are practicing what we preach, rather than superficial assessments to gauge whether we have the appropriate policies in place.

You can be sure the usual issues that have arisen in past surveys will be high on our list of improvement targets. Key issues include the following:

We need to improve our rate of medical record completion and the signing of verbal orders, either written or input through the physician order entry system (Last Word).

We must make sure all patients scheduled for surgical procedures or conscious sedation have up-to-date histories and physicals that are appropriately documented in their charts.

We must use the proper restraint protocols and include the appropriate documentation justifying their use (see article on page 3).

Medication safety is a key issue of concern. Non-specific orders such as "laxative, enema or antacid of choice" are no longer acceptable.

We must all be familiar with the list of unacceptable, unsafe abbreviations.

All medical staff members should be familiar with and understand the implications of the Emergency Medical Treatment and Active Labor Act, or EMTALA.

We should all be very familiar with HIPAA and its ramifications for the confidentiality of patient information.

On these and other issues, our physicians, residents and nurses must be able to articulate the appropriate policies and practices. As a helpful reference, the hospital's bylaws, rules and regulations are on the Stanford Hospital & Clinics Web site, at: http://stanfordhospital.com/forPhysiciansOthers/physicians/ medicalStaffServices/index.html

Just as we need to be prepared for a disaster at any time, we must always be ready for a visit from JCAHO or the state health department.
If you have questions about our continual-readiness efforts, please contact me at lshuer@stanford.edu; Rebecca Partridge, director of accreditation and regulatory affairs, at 723-2124 or Rebecca.Partridge@medcenter.stanford.edu; or Nancy Lee, vice president of clinical services, at 725-6089 or Nancy.J.Lee@medcenter.stanford.edu.