JCAHO requirement? hourly rounds and written report at change of shift?

[blackberry, BSN, RN]

I've seen the discussions on hourly rounds. My manager claims they are a JCAHO requirement as well as a written report instead of taped for change of shift.

For the next shift, the nurses fill out a written report sheet for the next shift.

Our form has three column: night, day and eve. The night shift makes a copy of the master copy that was completed on admission for the patient. A new form is completed every 24 hours. The sheet is kept for 48 hours and the old sheets are shreded.

My manager claims this is JCAHO. The only thing I know that JCHAO requires is that nurses be able to have a verbal exchange regarding the patients at change of shift.

I don't believe our report is JCAHO. How can I find this out?

Also, are hourly rounds JCAHO? :anbd:

[pezzy68]

We a few years back, stopped taping report and used paper report.The majority of us HATED IT.It was very hard to not right a novel when alot of things were going on w/ each pt.It seemed to me a very childish way to try to convey important information.When we switched, it was not due to jacho regs, i am not sure if that is a regulation or not, i do know alot of wierd regs are popping up nowadays, so nothing surprises me.Management changed to try get report through faster.We used to tape on one tape, all nurses, all pt's, you had to listen to all report till it came to your pt's.Since the written report didnt go well as they had hope, we switched to each nurse taping on their team only ,each on their own tape.Instead of the oncoming shift making out teams, the shift already on, makes out the assignment for the next shift.It works out well, even tho alot of thought we would like it.

[ilstu99]

We do verbal, bedside reporting hospital-wide, and we also have to document an hourly patient check.

I don't know if it's Joint Commission thing or not, but that's how we roll.

[ilstu99]

Page 7 from:

http://www.jointcommission.org/NR/rdonlyres/13234515-DD9A-4635-A718-D5E84A98AF13/0/2008_FAQs_NPSG_02.pdf

[2E] Our nursing staff prefers to audiotape the change-of-shift report. Is this acceptable?

We do not specifically prohibit the use of taped reports. However, this method will not be acceptable unless it includes an opportunity to ask clarifying questions and to receive answers in a time frame that is consistent with having complete and accurate information available to the patient's caregivers when they are providing the care. [Revised 3/08]

[locolorenzo22, BSN, RN]

verbal instead of taped...yep...

hourly rounding....I don't know about that...but it sounds like a good idea, within reason. I don't believe that is JACHO, but may be part of your facilities inititive to be JACHO certifed....

[Roy Fokker, BSN, RN]

A new form is completed every 24 hours. The sheet is kept for 48 hours and the old sheets are shreded.

If it's JCAHO mandated, why shred the "evidence" ?

Where I work, we answer to a higher god than JCAHO: Press-Ganey Woe betide the nurses who don't frequently round on their patients...

[ilstu99]

In my looking around, I found this page regarding shift change reports:

http://www.jcipatientsafety.org/22844/

I haven't seen anything specifically regarding hourly documentation, but it would certainly play a part in several of the PSP's noted on the JC page.

[medsurgrnco, BSN, RN]

Last I knew JCAHO did not require hourly rounding or written shift reports. If they did require written reports, those would not be shredded as hospitals would want proof that they are in compliance. Hourly rounding sheets often are not part of the patient record, or kept for any length of time, indicating they are not a requirement.

[Riseupandnurse]

We quit taped report as it was taking too much time and moved to SBAR. SBAR included written minisheets but nobody was keeping them up to date and we kept getting confused about how old a sheet was. Now we just grab our own Kardex copies and go off with the nurse who had our patient on offgoing shift. Funny thing is, it is now taking as long to get report on 5 or 6 patients as it did to listen to 20 or so on the tape. Written reports aren't part of JCAHO, but I understand Kardexes are required. Hourly rounding isn't JCAHO; it's coming out of the same pot of REALLY BRIGHT IDEAS THAT DON'T WORK AT ALL that managers around the country dip into regularly. And I really like the poster who said that they answer to a higher god than JCAHO, and that is Press Ganey. Oh, so very very true.

[bobbysgirl]

Hello,

We incorporated rounding to ensure that our patients had everything they needed and as a check. It is a preventive measurement.

I am revamping and streamlining hospitals's general orientation while satisfying JCAHO. I am looking for sample agendas to help with this process. If anyone is willing to share or has ideas, please post. Any help is appreciated.

[Up2nogood RN, RN]

We use hourly rounding and bedside report for reasons other than JCAHO, press ganey and Magnet have changed our practices more than JCAHO.

I have to write a short written report for the charge nurse's and rate acuity, the cna's, and give a face to face report to oncoming nurse (a little redundant). I had to stay and wait 30 minutes not too long ago to give report to a nurse who was late. It was already 7:45 (should have clocked out at 7:30) and had to wait another 30 minutes. The NM wasn't in that day but I was told that there was a sentinel event recently so the charge wouldn't take report from me and give to the oncoming nurse. We we going to a house-wide SBAR type form to be used at bedside report for all units in 2011.

[HouTx, BSN, MSN, EdD]

Interesting, isn't it - how it seems that leaders are sidestepping responsiblity by blaming everything on JCAH or CMS., Magnet or some other regulatory agency???

The truth is, that the vast majority of regulations are written about OUTCOMES - not process. For example, they require something like "effective process to ensure continuity of care". Then managers come up with all kinds of forms, processes and procedures that (in their opinions) will ensure that the outcome is achieved. Then, they say that the 4 new forms are a 'JCAH requirement'.....

FYI, the whole 'hourly rounds' as well as 'scripting' (Is there anything else I can do for you? I have the time) were first promulgated by the Studer group... as a way to improve patient satisfaction.

There appears to be a real deficit of effective management behind all this mess. I think a better approach would be to actual involve bedside nurses. Tell everyone what the regulation is - and ask everyone for their ideas about how to meet it. Nurses are very creative and intelligent - it is a shame that they dont' have more influence.