A little help, please, JCAHO stuff

[river1951]

Hi, Our QM department, bless them, has decided to fulfill JCAHO reqs we need to have an intervention for our care plans that tell us when to call the MD for O2 sats ( we must have a range) We tried to finesse it by saying we would contact the MD for unexpected O2 sats below 90%, but they won't buy it. How are other agencies getting around this. The MDs think we call them too much any way. I would appreciate any light anyone can shed on this-

Thanks so much in advance.

[doodlemom]

Is there a requirement to take O2 sats in the first place? If you don't know what someone's O2 sats are, then you would not have to worry about calling the doctor. We don't even own an O2 sat monitor, as it is expected that a patient's O2 sats will go down. We treat symptoms, not numbers. I'd be interested in knowing how others are dealing with this. We are JCAHO certified and we have a survey coming up again next year so I guess we might have this issue come up, as well.

[river1951]

No, there is no requirements to take O2 sats. In fact I discourage the nurses from doing them, we aren't treating machines and we expect the O2 sat to go down. No, I understand the requirment surrounds having a standard for any test you perform. I think JCAHO simply invents new requirements to keep themselves in business.

[doodlemom]

They're a pain in the ***, aren't they?

[Daytonite, BSN, RN]

This is something that I think your medical director of the hospice should get involved in. A policy should be developed. With a written policy behind you, the docs really can't complain. If you are part of a larger facility and these doctors are part of the organized medical staff, then this question should be put before the Medical Executive Committee. The Medical Executive Committee has the authority to help work with your division in developing guidelines on this. All, including the docs, have a mutual interest in complying with JCAHO. I'm surprised that the QM department hasn't suggested this or passed this problem on to the people on the medical staff already.

[river1951]

Well, we asked our medical director and he agreed with the wording "Inform the MD of unexpected O2 sat under 90%." The trouble is, our QM is HH driven and they don't always see the hospice picture. We have changed the wording very slightly and they finally agreed. Of course it is in our interest to comply, we have very high standards, at the same time the goals must be rational for your patient population. Thanks

[river1951]

And yes, they are a pain in the *** and the #$%^ also!

:bugeyes: