JCAHO standards for small, rural hospitals




How small, rural hospitals can prepare for a JCAHO survey

The main reason hospitals do poorly in surveys by the Joint Commission on Accreditation of Healthcare Organizations is they simply don't know what to expect in such a visit, said Charles P. Coe, v.p. of medication safety at Owen Healthcare Inc., Houston.

Coe and other presenters at the ASHP midyear meeting in New Orleans described how pharmacists in small, rural hospitals could prepare for a JCAHO survey.

What changes to expect

One common mistake is not knowing the changes in standards, said Coe. JCAHO recently instituted new standards for anesthesia, pain assessment and management, patient safety, and staffing. Another increasingly hot area is medication safety. "Surveyors will be looking more at processes to ensure the safe dispensing and administering of medications, rather than documentation and policies and procedures," he said.

Clinical practice guidelines are not yet required, but almost certainly will be soon, he said. You can also expect night, off-shift, and weekend visits, as well as unannounced surveys nine to 30 months after the initial survey. Finally, surveyors now look closely at deficiencies from the institution's past. "They know what happened in the last survey now," Coe warned.

Pharmacy's role in the survey

Records the pharmacy will be required to provide are P&T minutes—if the hospital supplies these, look them over yourself first, Coe recommended; ordering and prescribing policies and procedures; and records on medication use activities, including medication safety team records and adverse drug effects records. Even fire and health department inspection records may be requested.

Said Coe: "Questions that pharmacy might be expected to answer in various sessions could include the following: How do you obtain drugs not on the formulary? What about after-hours? How do you monitor drug therapy? How do you review medication errors? What definition of an error do you use? How do you ensure the safe continuation of patient care for patients on investigational drugs? How are you made aware of potential food-drug interactions?"

During the building tour, surveyors will look at the hood cleaning log and certification and medication area inspection records. Pharmacy manager interviews will be short, but managers may be asked about fire safety, evacuation routes, procedures for spills of hazardous material, and material safety data sheets. Pharmacy directors are interviewed in the department director interviews. Pharmacists may also be asked to sit in on other sessions if they have a role in infection control, performance improvement, or other areas.

A significant session for pharmacy is the patient care setting tour. For this, pharmacists should be certain that carts are replenished in a timely manner, patient charts are frequently reviewed, and you are able to answer such questions as which patients are on intravenous and which are on oral medications. Also, be ready to describe how you educate your patients about drugs they will be taking home, as well as what you've done to improve patient safety.

A new emphasis on med safety

Indeed, surveyors will focus closely on medication safety, cautioned Patricia C. Kienle, medication safety manager at Owen. She recommended the following steps to prepare for a survey:

• Know about high-risk and sentinel alert medications, and make and monitor appropriate changes concerning these.

• Ask your quality improvement department what two indicators your hospital has chosen to monitor for the JCAHO. These may concern pharmacy.

• Adopt a definition for adverse drug event. Then, be sure to put this definition in the P&T minutes and reaffirm it annually. Log on to if you need help.

• Make sure you have ways of identifying adverse drug events (ADEs) and improving the process for eliminating these.

"Choose high-priority, doable improvements, and document and monitor these continually," advised Kienle. Sentinel alerts and problems specific to your institution are good places to start. She recommended eliminating abbreviations, especially U for "unit" and any abbreviation for "day"; using premixed products whenever possible; checking computer labels for legibility; and developing a way to double-check infusion pump settings. "Also, do you know the lab panic values for your patients?" she asked. "You should."

Competence assessment

Competence assessment is also a tough nut to crack, noted Lee B. Murdaugh, medication safety manager at Owen. "About 25% to 30% of hospitals receive a Type 1 recommendation in this area," she said. Basically, JCAHO focuses on these questions:

• Is competence assessment specific for each job position?

• Are competence standards predefined and objective?

• Is performance measured against these standards?

• Are initial as well as ongoing assessments documented?

• Are there annual staffing effectiveness reports, and what actions are taken in response to analysis of these data?

"Everyone in the pharmacy must be assessed, including interns, support staff, volunteers, and temporary personnel," said Murdaugh. This should be done initially and throughout employment, as well as when there is new or updated equipment. When assessing pharmacy personnel, it's important to include competency in age groups served; special populations of patients served; dispensing and IV preparation; equipment use, safety, and security; infection control; and job-specific skills. The best method of assessment is a combination of verbal tests, skills demonstrations and checklists, and random direct observation, she said.

In terms of staffing, JCAHO looks at rates of overtime, vacancy, satisfaction, turnover, the staff plan versus the actual number of staff, staff injuries, sick time, and the use of on-call and per-diem personnel. "Clinical service indicators include family and patient complaints, patient falls, ADEs, patient injuries, skin breakdown, pneumonia, post-op infections, urinary tract infections, upper GI bleeds, shock, cardiac arrest, and lengths of stay," Murdaugh said.

Personnel records should be complete and up-to-date and include licenses that have been verified with the state board, orientation records, education and training records, the job description, signature of the employee, and all performance evaluations.

Tackling control of meds

Another closely observed area is control of medications, said John Uselton, director of accreditation services at Owen. "The pharmacist's review of every medication order prior to administration is looked at in every survey now," he said. There are only two exceptions: if a physician takes ownership (as in the ER, OR, or GI lab) or if there is an emergency.

Advice for this part of the survey includes developing automated systems or night carts to keep nurses out when the pharmacy is closed, and requiring two nurses, rather than one, to take a drug out.

Other security musts include the following:

• All drugs in accessible areas, including medication carts and refrigerators, must be locked.

• All wastage must be witnessed and documented.

• A process to reconcile controlled- substance records should be in place.

• Anesthesia carts, workrooms, and cabinets should be locked.

• Syringes must be labeled correctly.

• All expired supplies and medications, including those in carts, should be removed.

• A system for logging in and controlling samples should be developed.

• All temperature logs should be complete.

Finally, be sure surveyors see all documentation on improvements that have been made. And once the surveyors are there, "try to relax," concluded Uselton.

Debbie Epstein

The author is a writer in New Jersey.

Boning up for a JCAHO survey

Hospital pharmacists have a number of important resources they should consult to prepare for a survey by the Joint Commission on Accreditation of Healthcare Organizations. These include:

• The ASHP publication Preparing the Pharmacy for a Joint Commission Survey, which includes standards reviews, guidelines, and checklists.

• Competence Assessment Tools for Health-System Pharmacies, by Lee Murdaugh, a competence assessment guide.

• JCAHO ( ) resources, including FAQs and Sentinel Event Alerts, available on its Web site.

• ASHP ( ) resources, including ASHP Practice Standards, available on its Web site.


Debbie Epstein. READY, SET, SURVEY!. Drug Topics 2002;4:hse28.

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