Published in the September 2012 issue of Today’s Hospitalist
FOR THE FOUR HOSPITALS IN THE HEALTHEAST CARE SYSTEM in St. Paul, Minn., 2012 will be remembered as the year of the Joint Commission. Already this year, the Joint Commission has conducted a full-hospital survey of two of the hospitals, as well as a bevy of disease-specific surveys, including addiction medicine (two hospitals) and orthopedics (system-wide). Another full-hospital survey is expected this year within the system, says HealthEast hospitalist David Frenz, MD.
As the system’s medical director of addiction medicine, Dr. Frenz has already spent one day each with two different surveyors who were scrutinizing care in the system’s chemical dependency services. He says that for the second survey, which took place just two months after the first, “I got the call while I was in the shower. ‘Your clinic today is cancelled, and you need to report to the boardroom.'”
As Dr. Frenz is quick to add, “It wasn’t my first rodeo.” He’s been through two previous Joint Commission surveys, as well as state licensing and DEA surveys. But the extent to which “everything is fair game” in a Joint Commission survey was still an eye-opener.
Here’s what Dr. Frenz says hospitalists can expect when the Joint Commission comes to call, and how the survey can help your hospital.
Did you do any prep work before any of these surveys?
We were able to glean information from other local hospitals, which gave us a sense for what the Joint Commission has been focusing on. This allowed us to conduct a hospital-wide sweep to address possible issues. HealthEast also created a nice brochure for employees, outlining hot items. In the end, however, you can’t really “cram” for this exam; either quality is part of your culture or it’s not. And if it’s not, the surveyors are going to find problems in a hurry.
You mentioned being a veteran of other Joint Commission surveys. Were surveyors looking for the same things last time?
Those priorities always change, and they always have new things on their radar. A couple of years ago, it was individual treatment plans. Surveyors didn’t want to see just the boilerplate stuff that an EMR will spit out for you that’s not very specific to individual patients.
This time, the whole tracer process where you troll through the chart was newish, as was their emphasis on medication reconciliation.
What’s the tracer process?
It’s a way to broadly evaluate a whole system by selecting a patient and then using that patient’s record to move through an entire organization. Once surveyors initiate a tracer, they can crawl anywhere they want in the organization.
Of all the managers for addiction medicine, I was most familiar with the electronic health record because I use it every day. So by default, it was my role to navigate through the tracer process. I spent at least two hours with one of the surveyors on it, working off my laptop.
How do they pick a patient to trace?
Randomly. They identify all the active patients on the census that day, then randomly pick one and say, “Open the whole record, please.”
That particular patient came in through an emergency department at one hospital, then to a psychiatric ward and then transferred to another hospital. So the surveyor was looking at all these transitions from a med-rec standpoint.
He looked at a dictation from one of my partners “the care was delivered at a sister hospital that wasn’t being surveyed “that randomly mentioned the patient’s history of migraine. The patient was managing it with a sort of cream from India.
The surveyor looked at me and said, “You think that made the med rec?” And I’m like, “No chance.” But that gives you a sense of what a deep dive they’re doing.
Were they interested in your patient satisfaction scores?
That particular surveyor was actually cynical about the standard metrics that we’re paying big bucks for. Take, for example, “Would you recommend HealthEast to a relative with a similar condition?” We showed him those data and he said, “I’ve never seen anything less than a 75, so it’s just useless. How does that help you improve your organization?”
The kinds of quality improvement they were interested in were at the point of care and specific to the illnesses being treated. We walked one surveyor through the scales we use to track symptom scores, one of which has to do with depression. We could show that depression scores for individual patients went down longitudinally, which showed disease recovery. That made much more sense to them.
What did they find that needed to be fixed?
For one full-hospital survey, we got 15 citations, five of which needed to be remedied in 45 days and 10 within 60 days. The big one our department is working on is improving suicide screening for patients receiving behavioral health services. The surveyors found that our screen wasn’t up to par because we weren’t asking about protective factors that reduce suicide risk, such as being married or employed. We’ve identified a validated instrument and are rolling it out now.
Did every problem they found turn into a citation?
No, and they seemed to appreciate efforts at immediate service recovery. If you’re able to fix problems on the spot, there’s no reason to issue a citation. During one visit, the surveyor noted a ceiling tile that was water stained, and we were able to have plant management replace it before the end of the day.
She also noted that we’d posted no disclosure about using video surveillance equipment outside our chemical dependency unit. We had security post a laminated plaque to that effect outside the entry doors
before the survey concluded.
When I was following her around that day, I kept track of her comments and sort of “live blogged” them to our Joint Commission point people. She made good suggestions, for instance, on how to make treatment plans more specific and goal-oriented. She also mentioned that we
needed to train staff in how to use the fire extinguishers and told us to put psychiatric advanced directives in place before our next full-hospital survey. But those didn’t turn into citations.
So was the process helpful or anxiety-producing?
Having done a number of surveys, you just accept that this is consultative. They’re not necessarily trying to bust you, but they’re definitely going to find things. When they do, it’s important to not argue or try to dissemble. They’re here to be helpful.
That’s what you’re paying for and what you expect. It’s supposed to be quality improvement, not just accreditation, so you want them to find things that you can correct.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.