If I were a JCAHO surveyor, I would conduct a hospital review of Nursing, Respiratory Therapy, and the Physicians on an unannounced basis. I would chose this method because it helps organizations provide safe, quality care that’s continuous, not sporadic in nature (DeLorenzo, 2005). As a means of pinpointing gaps in problems related to patient safety and quality and offer guidance to leadership, physicians and other members of the healthcare team, I will observe and interview the nurses, respiratory therapists, physicians, and perform patients and systems tracers (the Tracer Methodology) which puts the hospital in a position that forces them to prove that they practice what their policies and procedures require. My patient tracer will involve me randomly selecting patients from the unit, fitting the selection criteria: patients receiving intricate services, patients requiring the use of different programs and services, and patients associated with systems tracers (Murphy-Knoll, 2006). Once selected, I will tour the unit, interview the members of the healthcare team including nurses, respiratory therapists, and physicians, review the patients entire medical records and follow the patients throughout the entire process of their hospitalization. Anything related to the treatment of the patient is fair game: admission processes, x-ray, lab, medication management, patient confidentiality, physician credential and privilege issues, staff licensing and competency, housekeeping, charting and medical records, medical equipment, plant equipment, sterilization, and security (Snyder, 2005, p. 135). The entire process includes observing how the nurses, respiratory therapists, physicians and any other members of healthcare acknowledge the patients, wash their hands, confer with the patients, behave towards the patients and chart the care of the patients. From admission to diagnostics to surgical procedures to transport services, I will watch their interaction and observe what the nurses, respiratory therapists, and physicians do and say when they hand off patients to the oncoming or receiving shift. Always searching for answers and to understand, I will ask the healthcare team questions about what and why they do things in a certain way. My systems tracer will include several priority focus areas in both my general hospital
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In my general survey, I will verify whether or not initial assessments by consults were conducted, e.g. physical therapy, respiratory therapy, speech-language pathology, social work; consults were initiated based on screening criteria in the datasets, e.g. smoking cessation, PFT; there were no medical interferences or diagnostic tests performed without an order by the MD; the progress notes reveal multidisciplinary development and follow-through; and, there is patient understanding of education. In my survey of the work environment and fire and patient safety, I will confirm whether or not equipment is correctly cleaned and disinfected in between patient use with the appropriate hospital-approved disinfectant, there are no expired supplies being in stock or being utilized, HIPAA regulations are being complied, oxygen tanks are safe, secure, and properly stored, and hallways are kept …show more content…
Within a couple of weeks after the survey, I will make available the hospital’s elements of performance (EPs) scores that determine if a standard is in compliance: 0 = insufficient compliance, 1 = partial compliance, and 2 = satisfactory compliance (Facts about Scoring and Accreditation Decisions, 2015, para. 2). In Facts about Scoring and Accreditation Decisions (2015, para. 3), if the hospital receives any partially compliant or insufficiently compliant EPs, they must be addressed via the Evidence of Standards Compliance (ESC) submission process within 45 or 60 days, depending on the criticality of findings and immediacy of
In my general survey, I will verify whether or not initial assessments by consults were conducted, e.g. physical therapy, respiratory therapy, speech-language pathology, social work; consults were initiated based on screening criteria in the datasets, e.g. smoking cessation, PFT; there were no medical interferences or diagnostic tests performed without an order by the MD; the progress notes reveal multidisciplinary development and follow-through; and, there is patient understanding of education. In my survey of the work environment and fire and patient safety, I will confirm whether or not equipment is correctly cleaned and disinfected in between patient use with the appropriate hospital-approved disinfectant, there are no expired supplies being in stock or being utilized, HIPAA regulations are being complied, oxygen tanks are safe, secure, and properly stored, and hallways are kept …show more content…
Within a couple of weeks after the survey, I will make available the hospital’s elements of performance (EPs) scores that determine if a standard is in compliance: 0 = insufficient compliance, 1 = partial compliance, and 2 = satisfactory compliance (Facts about Scoring and Accreditation Decisions, 2015, para. 2). In Facts about Scoring and Accreditation Decisions (2015, para. 3), if the hospital receives any partially compliant or insufficiently compliant EPs, they must be addressed via the Evidence of Standards Compliance (ESC) submission process within 45 or 60 days, depending on the criticality of findings and immediacy of