UAB Synopsis, Vol. 27, No. 12, March 31, 2008
By UAB Hospital Associate Chief of Staff Waid Shelton, MD
The Joint Commission (TJC) mock survey of UAB Hospital just completed showed our performance generally improved compared with the October 2007 survey. However, it shined a light on opportunities for improvement in several practices that concern patient care and safety. This effort is especially important because we expect the survey for accreditation by TJC to begin one Monday morning in the next 2 months. The inspection will last 5 days and will involve eight inspectors who will visit all parts of the hospital and the departmental and divisional offices — often more than once.
Verbal orders were scrutinized in the mock survey, looking for situations in which nurses might write verbal orders for what they knew to be a doctor’s standard practice without talking with the doctor and without instruction of a written protocol. Discovery of this practice in other hospitals has severely impacted their accreditation. Also, TJC regards relying on verbal orders for conducting routine patient care as a risk for patient safety. Hence, it is critical for everyone to understand what TJC mandates about verbal orders.
Verbal orders should reflect a conversation that is held in the case of an emergency or the physical absence of the physician. Verbal orders are given by the physician, written down and then read back by the nurse, and finally acknowledged by the physician. Verbal orders cannot be used for the physician’s convenience, simply to save time when visiting the patient. Nor can they be used by the nurse in the absence of a written protocol to avoid interrupting the physician.
The mock survey reviewers also looked to see if physicians signed or authenticated verbal orders they gave. The Centers for Medicare and Medicaid Services (CMS) require all verbal orders be signed within 48 hours. We must conform to CMS guidelines.
Hand-offs were reviewed in several situations, including when the patient’s care is transitioned from the emergency room to the inpatient service and when the care of an inpatient is transferred from one physician to another. Hand-offs must be done in a standard fashion, and the situation must have minimal interruptions with the opportunity to ask questions and receive answers about each patient. TJC is aware that care of any particular patient may be handed off more than once in a day, and these hand-offs are a focus of caution because they provide an opening for misunderstanding.
Consents and time-outs were examined. Consent forms must contain the correct procedure, the name of the physician performing the procedure, and the signature of the physician who obtained the informed consent. Consent forms must be completed and reviewed as part of the time-out before the procedure. Time-outs are required for any procedure that requires consent, whether it is a major surgical procedure or a joint injection.
Time-outs should include all participating persons. Even relatively minor bedside procedures should be done with the nurse in the room for the time-out. The time-out documentation, including document review, patient identification by name and medical record number, identification of the correct side/site, correct procedure, correct position (if applicable), and correct special requirements (if applicable), must be completed before the start of the procedure. The physician must sign, date, and time the note. If the physician is scrubbed, he may delegate this responsibility to a proper designee.
For surgical procedures and those procedures involving conscious (moderate) sedation, a history and physical must have been completed within the past 30 days and updated within 24 hours before the procedure – a progress note or anesthesia note can meet this 24-hour updating requirement. Immediately before starting a procedure involving conscious (moderate) sedation, the physician must examine the heart, lungs, mental status, and airway (mouth and oropharynx) and document the findings. Also, the American Society of Anesthesiologists’ sedation level must be noted in the record.
Syringes with medicines used in procedures or in bedside pushes should be labeled with the medicine name, dosage, and date/time drawn up if their contents are not used completely and the syringe is not discarded. This is true if there is only one syringe involved.
Medication reconciliation is different for inpatients and for outpatients treated at UAB Hospital. Both processes involve the purple sheet identifying all the medicines taken by the patient at home. For inpatients, the purple medicine sheet is completed by the nurse, reviewed by the physician, and considered in the patient plan of care. At discharge, the physician reviews the purple sheet and the medicines the patient has taken in the hospital. Then, the physician lists in the PIN discharge pathway all the medications the patient should take, both those formerly taken at home that are to be continued and those from the hospitalization that are to be continued. The PIN discharge sheet is given to the patient at discharge. The medicines in the PIN discharge sheet must match the discharge medicines in the discharge summary, which is then directed to the next provider of care.
For patients treated at the hospital but not admitted as inpatients, such as emergency department, endoscopy, or heart and vascular laboratory patients who are discharged from these physician directed areas, the purple sheet with home medications is completed by the nurse or reviewed by the nurse when completed by the patient or family member. The physician reviews the purple sheet as a part of treatment or before the procedure. Before discharge, the physician again reviews the purple sheet and changes it to include medications newly prescribed or stopped. A copy of the sheet is given to the patient at the time of discharge.
We have a multidisciplinary approach to patient care at UAB Hospital, but we often take it for granted and do not refer to various team members who help our patients when we write notes in the medical record. Progress notes should refer to and document the participation of the nurse, care manager, social worker, physical therapist, dietician, pharmacist, chaplain, or consultant.
Hand washing is something we must do before and after seeing every patient. Also, we should gown and glove when entering the room of a patient on contact isolation.
Abbreviations and amounts that can be misinterpreted should not appear in any part of the medical record. PIN uses these abbreviations, but they will be discontinued soon. You should never write the abbreviations: U, u, IU, QD, QOD, MS mg, MSO4, and MgSO4. You should never use a decimal and trailing zero (X.0), because the decimal might be missed. For the same reason, you should never fail to use a leading zero with a decimal (0.X).
Two identifiers are required for each patient, and those are the patient’s name and medical record number. Both are found on the patient armband.
The Joint Commission interview process involves talking with TJC inspectors. They are nice and courteous and deserve the same attitude and response from us. You should use a simple, conservative strategy in which you tell the actual process we follow for good, quality care. In no circumstance should you make up things because you think that is what the inspectors want to hear. If you do not know the answer, tell the inspectors how you will follow the chain of command to get the answer, such as asking the nurse manager, the medical director of the unit, the director of nursing, the associate chief of staff on call, or the administrator on call. Also, answers to many questions are found on the yellow and white hang tags behind our identification badges. The yellow tags contain correct responses about fire and other hazards. The white tags address many of the patient safety rules discussed in this article. You can refer to them when responding to a question from a joint commission inspector. Yellow tags are available from Hospital Personnel, and white tags are available from Patient Safety.
Inspectors want to hear about quality improvement projects on the units that they visit. Be prepared to discuss them and offer to do so.
Accreditation is important because our ability to care for patients, to teach residents, and to do clinical research is tied to it. Also, our reputation in the community and the state is at stake. We know we have the will, the skill, and the heart for excellent, safe patient care. The visit from the Joint Committee offers us the opportunity to demonstrate this.