Key Survey Issues for Practitioners

Communication – written abbreviations

• Refrain from using the JCAHO “Do Not Use Abbreviations” (DNUAs)

Communication – verbal or telephonic orders

• Verbal/telephone orders should be used infrequently

• Verbal/telephone orders require that the Texas Children's staff member taking the order write it down and read it back to the ordering physician for confirmation that it was appropriately understood

Communication – reporting critical values

• TCH follows a policy of notifying the physician for those tests results that are considered to be significantly high or low enough to be considered a “critical value”

• When contacting a physician with test results, Texas Children's staff will request that the physician write the results down and read it back

Safe Use of Medications - procedures

• Label all medication containers (for example, syringes, medicine cups, basins) or other solutions on and off the sterile field

Safe Use of Medications – reconciling medications

• Reconcile a list of the patient’s current medications at: admission, transfer, discharge, and each clinic visit

• Communicate current medication list to the next treating practitioner

Infection Control Practices

• Hand hygiene (washing or use of foam according to CDC guidelines)

• Use of appropriate standard precautions

Invasive Procedures – Universal Protocol

• Pre-Operative Verification Process

• Mark the operative site

• “Time Out” with documentation, immediately before starting the procedure

Treatment – alternatives

• When informing patients of alternative care or treatment, also inform them of the associated risks, benefits and side effects

Restraints

• Follow policies for time requirements to reassess and reorder—different requirements for behavioral versus medical restraints

Privacy & Confidentiality

• Place medical records in the appropriate drawers or assigned areas when no one is in attendance

• Close computers sites containing patient information when no one is in attendance

• Refrain from conversations that contain patient protected health information when in public areas

Documentation Issues

• Follow Medical Staff Bylaws regarding content and timing of medical record documentation

Hot Issues for JCAHO

• Write legibly

• Include pager or telephone number with your signature

• Do not write “Blanket Orders” (resume previous orders)

• Include all required elements in a “Post Operative Note” immediately following procedure (pre-operative diagnosis, post-operative diagnosis, name of procedure, findings, surgeon name, assistant surgeon name, specimen, estimated blood loss)

• Update H&Ps prior to performing a procedure, or indicate “no change” in the medical record

• Write date and time of each entry

• Complete the Summary list by third clinic visit

Performance Improvement

• Reports measuring compliance for many of the above items are routinely reviewed at medical staff department meetings

Peer Review

• Outcome studies – based upon use of recognized standards/practice guidelines

• Individual adverse event case review

Credentialing

• Review of performance data including morbidity and mortality data before granting privileges