Our "final exam"

Everyone knows what it is like to prepare for a final exam. The last minute cram sessions. The study lists. Classmates challenging one another with questions and answers in late night study groups. But it's a rare person who can make up in a few cram sessions for studies otherwise neglected during a semester's classes.

This week was a kind of final exam for Community General Hospital. The examiners were on-site surveyors from the Joint Commission, the body that accredits hospitals. Yes, we have been cramming for this examination for some time, but it is not a test you can study for short-term. You have to be following the polices and processes every day in order to meet accreditation standards.

We did not know the date of our examination. But we knew that Community was due for a survey in 2010.

Last Tuesday morning the surveyors arrived on campus unannounced for the four-day examination. Throughout the week they met with patients and caregivers, they reviewed our policies and processes, observed a surgical procedure, reviewed performance data, and they met with board members, physicians, nurses and support staff.

The Joint Commission has four categories of scoring:

1. There is an immediate threat to life.

2. Specific situations prompt a preliminary accreditation denial or make an accreditation conditional.

3. There is a direct impact on safety or quality

4. There is an indirect impact on safety or quality.

First, I am glad to say that Community did well. Although we won't have the final results for ten days, it appears we will receive a full three-year renewal of our accreditation.

Second, we learned a lot.

It is not strange to say that our learning continued, even during this "final exam." The surveyors score the hospital on what they find, grouping the findings into the four categories summarized above.

But the point of the survey is not only to check off "wrong answers." It is also a collaborative process, and that means surveyors suggest ways to achieve better results. They told us what other hospitals are doing, and they gave us examples.

In some cases, the surveyors asked us for copies of policies, forms, or data displays that they thought were effective and could benefit others. I was happy to hear that Community demonstrated good team work and showed evidence of good patient care. But we are far from perfect.

The surveyors cited Community for seven direct findings and for 12 indirect findings. We have six to eight weeks to address these issues, depending on whether it is a direct or indirect finding.

Here are the surveyors' findings in areas that have direct impacts on safety or quality:

▪ Managing safety: Documentation of weekly checks of emergency eye wash stations was missing in two areas. There were several instances where call-alarm pull-cords were wrapped around grab bars. And a red bag (infectious waste) was improperly left in a patient care corridor in one area.

▪ Managing hazardous materials: In two cases, employees were not able to respond immediately to questions about what to do in the event of a formaldehyde spill. (Formaldehyde is toxic chemical compound.) Also, rooftop exhaust fans were not identified with bioharzard labels.

▪ Utility risk management: Electrical junction boxes were not properly covered in several locations, and proper room ventilation was not checked in a procedure room earlier this year when such checks were done on all operating rooms.

▪ Medical equipment: The daily check of a backpack containing emergency supplies was not documented, and checking an emergency cart in another area was not documented on three different days.

▪ Construction safety: The hospital's policy did not require temporary sign placement when an emergency egress route is temporarily changed during construction.

▪ Emergency exits: The sliding doors at main entrances had manufacturer-installed locking devices that compromised the breakaway feature in an emergency. Also, surveyors noted several instances where equipment in hallways partially obstructed corridors.

▪ Informed consent: There were two instances where the informed consent process was incomplete. In one case documentation did not include a patent's likelihood of achieving his or her goals. In another, the risks, benefits, and side-effects of alternatives were not documented.

In a few cases we were able to make changes on-the spot, such as the roof vent labels, junction box covers, and breakaway door switches. Other changes will take time, and we have Joint Commission deadlines.

There is work to do as a result of these survey results, and next week we start with a meeting of the Board of Directors. The survey shows how well we are doing things, but the real goal is to get better, and our "final exam" will help us do that.