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PostPosted: Wed Jun 07, 2006 10:15 pm    Post subject: Preparing for a JCAHO visit (Article) Reply with quote

Preparing for a JCAHO visit

When inspectors from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) came to the University of North Carolina Health Care System, they headed to JoAnn Belanger's radiology department first.
"I don't know why," Belanger said during a talk at the 2005 RSNA meeting in Chicago. "I guess they just thought radiology was the place to start."

Belanger, a registered nurse, manages patient services in the radiology department and the endovascular clinic at the Chapel Hill, NC-based medical center. She's been through her fair share of JCAHO visits during her 21 years in healthcare. She recalled a JCAHO surveyor who said that the technology of radiology was akin to the gadgetry of a "Buck Rogers" TV episode. She also remembered being able to maintain department information in a stack of notebooks that she showed to JCAHO officials. Now there's far too much information to keep on one shelf, she said.

"Our lives have changed," Belanger said. "People don't understand how different the radiology department is these days." Likewise, the JCAHO's requirements of radiology staff have also changed.

JCAHO goals

According to Belanger, JCAHO's top priorities include the following:

Improving patient identification
Improving communication between caregivers
Improving accuracy of drug administration
Improving drug documentation throughout the continuum of care
Improving IV pump safety
Maintaining accurate clinical alarms
Eliminating wrong site, wrong patient, wrong procedure, or wrong surgery errors
Reducing healthcare-acquired infections (HAIs)
Reducing falls
Addressing flu and pneumonia causes in older patients
Reducing surgical or procedural fires
Along with new safety goals comes the arrival of the unannounced survey process. Now JCAHO officials may appear unannounced at an agency's front door. And rather than simply visit with heads of departments to mull over hospital policies and paperwork, they may pull a patient file and mirror his or her progress throughout the day, asking all employees involved whether they understand the underlying safety provisions.

Belanger said radiologists need to be prepared for a JCAHO auditing team to drop by at any time. "They don't call you up and set up an appointment," she said. "They come in and want to make sure you know your stuff."

Getting a radiology team up to JCAHO standards doesn't need to be a harrowing experience, however. Belanger suggested involving the entire team because more people mean more ideas and better outcomes.

The more the merrier

The nursing staff in Belanger's radiology department are cross-trained to provide care in CT, adult and pediatric x-ray, breast imaging, ultrasound, nuclear medicine, MRI, the endovascular clinic, and interventional radiology (both vascular and neurological).

"The nurses work independently to provide specialized care to a diverse population of patients," she said.

Their duties include administering medications, monitoring and managing patient crisis, and educating patients about the department. Radiology nurses oversee patient care in a technically oriented environment. It is this type of training and teamwork that makes her department so successful, she said.

"All these ideas come from my team," Belanger said. "They have so many ideas. If you just ask, you'll be amazed at what they can come up with," she said. "It's a good team effort, and that's what JCAHO is looking for within the whole institute."

Right meds for the right patients

For example, Belanger's team resolved one JCAHO goal -- improving accuracy of drug administration -- by using a simple tool from elementary school. Her team started carrying around colored pencil boxes. Each box contained a specific patient's medication to ensure that patients receive the correct doses.

"Everyone has an example of a problem like this," Belanger said. "It's an issue for nursing and the radiology technologists. By labeling the medications and keeping them in the right box, we can be sure the syringe doesn't get mixed up with any other meds."

Hand washing -- no water!

To comply with the HAI safety goal, JCAHO recommends following the U.S. Centers for Disease Control and Prevention guidelines. Simply put, wash your hands at every opportunity. But Belanger's staff complained that there simply weren't the facilities to keep hand washing within arms' reach. So they recommended putting antibacterial liquid hand-washing dispensers at high-traffic areas throughout the department. Within days, the number of staff who washed their hands doubled, she said.

"It's amazing what you can come up with," she said. "And these simple solutions solve life-threatening problems."

Reconciliation of pharmaceuticals

Despite her more than two decades of experience and the collective experience of her crew, Belanger is still concerned about certain JCAHO safety goals. Improving drug documentation throughout the continuum of care causes the most consternation.

"The reconciliation of medication across departments is the biggest deal," Belanger said. "We're a 700-bed hospital. I have 150 CT scans scheduled on any given day. How are we going to keep track of all that?"

Belanger and her team have so far resolved to document medications within the radiology department. They'll add medications to a patient's list if they are administered within the department. But it's not a suitable system for outpatient services, she said.

"We have patients who come to us with enough medications to fill a garbage bag," Belanger noted. "How are we ever going to be able to track that in a radiology department?"

Reduction of falls

Preventing falls is also an issue of concern for Belanger and her team.

"How many of us have had a patient fall off the table?" Belanger asked. "We all know that despite our best efforts, some of these patients just want to get up and go for a walk rather than sit still."

The job of a radiology nurse or technologist makes it difficult to remain at the patient's bedside constantly, so Belanger's hospital established a falls committee to investigate best practices for keeping patients safe.

"Do we use restraints to reduce this risk, or don't we?" she inquired. "If we use them, they may work, but there's also evidence that patients find a way around the restraint and possibly injure themselves worse."

JCAHO recommends the following tips for preventing falls:

Orient the patient to the room.
Tell the patient about the facility's fall prevention policies and procedures.
Keep the room free of clutter and spills.
Keep the room as well-lit as possible, particularly when escorting patients to and from the room.
Provide and document patient and family education about fall precautions.
Preparation and constant diligence are your most valuable assets, Belanger said.

By Melissa Varnavas contributing writer
April 18, 2006

This article originally appeared in the "Radiology Administrator's Compliance & Reimbursement Insider," a monthly newsletter published by HC Pro that is designed specifically for radiology administrators.


Joined: 16 May 2012
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