Joint Commission - NPSGs

homehealth43130 · Feb 18, 2007

We audit handwashing at supervisory visits- hits everyone at least once a year as we do an supervisory visit for yearly evals on everyone. I ask 10 people each month what our patient identifiers are. I spread it out so that everyone - even non-visit staff get asked. I sit at intake several times a month and listen to them taking orders for the read back of orders and critical labs - I try and keep busy doing something else so they don't know what I am actually doing - but I am sure they do know. We keep a running log of our critical labs and time of notification of physician which I tabulate each month. When unapproved abbreviations were first implemented, I did 100% review for thoes, but now just hit it quarterly as part of our quarterly chart audits for CMS. We have a policy and procedure in place for oxygen and fire risk in the home and each time we need to implement this, I record it on a log for The Joint Commission. Hand off report is the one we are having most problems with - we instituted the sbar and got some really nice samples off http://www.medqic.com. I don't have a formal audit tool for most of these, I record all the audit result information for The Joint Commission on a exell spread sheet with graphs, but I do keep copies of the form that I used to record results on.

Keeping up with all the auditing is a full time job. I try to combine several audits at a time. If I am looking at our ACH charts, I also do the medication audit - for our OBQI project and medication reconcilliation. I am looking at advance directive information as well as some other documentation areas while I have the chart out. I find this works well for me.

I try to keep my numbers small - usually 10 - 20 each month since most of our thresholds for The Joint Commission is 90%. I keep my audit questions simple usually answered with yes, no, n/a.

I have found audit tools on the medqic site, and your qio rep should have some or be able to get some for you. I have also found good audit tools on some of the list serves - NAHC has some good ones for OBQM if you are a member and that list serve is a good one - you do need to be a member to use thoes resources.

Hope some of this helps.

ALHHRN · Feb 19, 2007

It does help. Thank you. What is your average daily census? We do not have a person for audits/PI. It's a joint effort and I feel too like it is a full time responsibility.

homehealth43130 · Feb 23, 2007

We run between 180 and 200.

caliotter3 · Feb 23, 2007

At my last agency, the NPSG's were hardly an issue at all. Things were very disorganized between changes in mgmt and I had been on a leave of absence. In some of the charts of clients I found copies of the corporate policy letter, in other's nothing. None of my co-workers (I am not in a supervisory position) could ever tell me about any of this. Apparently, no inservices were held nor were any info letters sent to anybody. I have no idea what the mgrs were doing to get into or show compliance. I saw aborted attempts by the previous mgr at implementing 2 items, but nothing to tell the field workers what was going on (other than reading the corporate policy letter, if a copy had been placed in a field chart).