Nutrition support in hospitals: What JCAHO is watching for

Nutrition support standards of JCAHO



Nutrition support in hospitals:
What JCAHO is expecting

What should nutrition-support pharmacists expect when an accreditation survey team comes to visit their institution? How should they respond if the team decides that the program rates a Type I recommendation that could threaten the institution's accreditation? (A Type I recommendation requires an institution to take corrective action within a specified time in order to maintain its accreditation.) What drug-nutrition interactions (DNIs) should be included on an institution's DNI list?

The answers to those questions were among the information given to nutrition specialists attending the 25th annual Clinical Congress of the American Society for Parenteral & Enteral Nutrition (ASPEN) in Chicago.

High on the list of priorities for the survey team will be accountability and documentation, according to Carole H. Patterson, MN, RN, director of the department of standards interpretation for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). "You will have to tell us on the first morning of assessment who is doing what and who has the authority to sign orders," Patterson said. "And everything you do needs to be documented."

Patterson gave nutrition-support pharmacists and other nutrition specialists attending the session an overview of the Joint Commission's standards and survey process and what to look for. Another speaker, Carol J. Rollins, Pharm.D., MS, RD, BCNSP, presented information on how to handle a Type I recommendation relating to nutrition services. Rollins is coordinator for the nutrition-support team at the Arizona Health Sciences Center in Tucson.

Under JCAHO standards, the initial assessment of a patient being admitted must include screening for nutritional status. This must be done by a qualified clinician who has the appropriate observation skills and who will understand the responses that are given. The clinician also must know what to do if the patient "fails" the screen, such as showing evidence of diabetes. In most institutions, this screening is done by a nurse who is trained to pass the patient on to the appropriate specialist, if that is required, said Patterson.

There also is a requirement for a nutrition assessment, which must be performed by a qualified dietitian or nutrition specialist. And the institution must have a nutrition therapy plan or guideline, developed by an appropriate interdisciplinary group.


Patterson said the survey team will spend the first morning examining documents. These will include policies and procedures, the defined roles of dietetic technicians, the plan for provision of services, the performance improvement plan, and the minutes of all meetings. The team will also be interested in the safe, accurate, and timely delivery of food and nutrition products, in the handling of special diets and altered schedules, and in how effectively patient response is monitored.

Surveyors will spend only the first morning of the first day of a visit in reviewing documents, Patterson said. The rest of the time will be spent in patient care areas. That is because the commission is seeking to institute a full systems analysis, which it has been working toward for the past four years. It hopes to put that approach in place by next year, Patterson said. "We are trying to increase our focus on analyzing systems and identifying where the problems are," she explained.

One aspect of that is looking closely at the "linkages" or "handoffs" in the processes of care. Another is increased attention to the "open" medical record, she noted. "We are increasing the time we spend on open medical records."

Patterson went on to explain that surveyors also will be giving increased attention to internal coordination and communications as a function of an institution's leadership. She indicated that a study of sentinel events has shown that the "root causes" are often related to lack of integration, coordination, and communication and that standards addressing these are rarely scored. That is going to change, she warned.

According to Rollins, the most common reason for an institution to receive a Type I recommendation from JCAHO on its nutrition-therapy program is failure to comply with its own established guidelines or failure to engage the appropriate disciplines in the development of the guidelines.

The first step in responding to a Type I recommendation relating to nutrition therapy, Rollins said, is to examine the existing system and determine where and why a failure occurred. This should be done by a team that includes appropriate practitioners as well as administrators.

Rollins emphasized that each institution must develop its own program to meet JCAHO's standards.

"There is no one right way to deal with it," she said. She cautioned against simply trying to copy another institution's approach. Although another's approach can serve as a guide or a point of departure, she said, simply trying to copy it will probably not work.

A successful program must fit the particular patient population and the structure and expertise within the institution, she noted.

Joseph Breu

Based in Chicago, the author writes frequently on health-related subjects.


Joseph Breu. Nutrition support in hospitals: What JCAHO is watching for.

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