This is a copy of the letter she sent to me...It didn't come from our management, and it isn't an urban legend. I left the hospital name on it and took off the people's names. Gee, I can't wait until they come to us! I'd like to know where they come up with this stuff!
I thought I would give you an update on our JCAHO visit so we can all benefit from each other. Here is what they focused on. They spent an entire day with us on our floor (LDRP and NICU). They asked to be paged when we did a c/s so they could observe, they observed a circumcision, followed a patient who came in to the ED s/p mva but pregnant and followed her to our floor (tracer). One thing I learned-don't offer any information they don't ask, only answer what they asked. The surveyor asked a nurse about our relationship with other departments like the ICU when we had critical patients like DIC and the nurse thought she was being helpful and told her about a past patient and the surveyor asked for the patient's name and went to medical records and pulled her chart to see what was documented, etc. Sorry for the long email but I was very surprised by how much time they spent on our floor.
--Hand hygiene-washing your hands when you enter any room and when you leave
--They watched a circ-wanted the betadine and water labeled on the sterile field (they asked the nurse how she knew the difference between betadine and water -her answer that betadine is brown didn't work)
--Time outs before circ and c-section observed
--They observed a c/s-watched for circulator not wearing gloves when documented in computer
--no chairs next to COW'S in the hallway (no unattended COW's for >30min)
--Bring kardex with you to the bedside with you when you give meds, use two identifiers
--they questioned staff on other floors/departments about infant abduction drills and what there role was
--asked how we screen for child abuse
--follow up documentation for temperature outliers
--no mixing meds even if pharmacy closed
--every nurse or doctor they questioned they took her name down and went to HR and looked up their credentials, competencies, expiration dates on CPR, NRP, etc
--focused on hand offs (nurse-nurse AND physician-physician)
--specimens labeled at bedside prior to sending
--VERY focused on teaching; asked to watch a nurse give bath demo, discharge teaching, watched LC give breastfeeding teaching; wanted to see pt response to teaching documented in computer; asked to see labor teachings-kept asking "how do you know your patient understood what you taught her"
--Liked the alarms for FHR in OBTV
--asked about backups of system, wanted to see downtime policy
--asked how we screen visitors for the flu, RSV season, etc. Wanted to know if we took every visitors temperature before being allowed in OB/NICU (anyone doing that??)
--asked about calling kidney-1 and organ donation for demises
--asked staff who shuts off the main medical gas valves
--documentation of immunizations for patients (flu vaccine, pneumococcal etc)
--reassessment of pain after giving pain medication
--All PRN meds had a PRN reason listed
--No range orders (i.e. 1-2 Percocets for pain, 2-4mg MSO4 for pain) (said the nurse is prescribing meds)
--asked about how we handle the two systems (meditech and OBTV) not being interfaced, asked if there were plans for this to happen in the future, what we did about pharmacy needing access to allergies, ht/wt for dispensing meds .
--wanted to see auto generated consults to SS if the patient asked for more advance directive information, gest diabetics and dietary consults.
Sorry for the long list. All in all we did well. Most of the stuff they said "were recommendations"
Perinatal Information Nursing Systems Administrator
Maternal Child Services