Publish Date: March 21, 2018
When Joint Commission surveyors come to your OR, there is good news and bad news about how to prepare, according to survey consultants Jenny Manderino, MSN, RN, and Robert Durkee, MHA, RN, FACHE.
The good news: there is nothing too new or surprising surveyors are looking for.
The bad news: surveyors are continuing to find the same poor practices not being addressed properly.
Know What To Focus On
To avoid penalties that could jeopardize your accreditation status, Manderino and Durkee suggest making sure these most frequent survey failures are in order:
- Incorrect Temperature and Humidity and Positive/Negative Air Pressure Parameters
Durkee says regular monitoring and close collaboration between perioperative staff and facilities staff can prevent big surprises with these parameters.
He advises that regular monitoring and any actions taken for adjustments be documented to indicate to surveyors that regular attention is being given to ensure these elements are maintained.
- Improper Surgical Instrument Handling For Reprocessing
Surveyors are carefully scrutinizing each step in handling surgical instruments for reprocessing, beginning at the point of use with adequate pre-treatment and including very specific steps with high-level disinfection and sterilization, Durkee explains.
For example, he says surveyors are noting improper testing of sterilization equipment for safety risks such as not using the correct class/category of indicator to monitor the sterilization process. For high-level disinfection, facilities are getting penalized for not testing minimum effective concentration (MEC) at the beginning of the day and before each load.
“We are also seeing surveyors be much more critical in their review of education and competency in the sterile processing area, especially for those who are overseeing the day-to-day work for high-level disinfection and sterilization of surgical instruments,” Manderino adds.
- Unsafe Medication Management in the OR
Required safety practices around medication safety, such as labeling medications on and off the sterile field and securing medications, are a big area for non-compliance, Durkee stresses. “Obviously, this is a huge patient safety issue, as well.”
Overall cleanliness in all areas of the perioperative environment is something surveyors are checking thoroughly, Manderino says. “Sometimes we see a general lack of cleanliness inside and outside of the OR that is a clear signal to surveyors that infection prevention practices such as cleaning high-touch surfaces are not being followed.”
- Not Fully Engaging in Every Universal Protocol Step
Despite being established in required practices for years, Durkee says it is not unusual to still see teams missing important steps in this safety protocol, such as not having the complete perioperative team fully engaged in the Time Out.
Be Ready For Survey Day
Some perioperative leaders find success on survey day when they run a “Game Day” checklist once surveyors have arrived to do a last-minute walk through of the department, Manderino explains. She says this checklist should include a double-check of the following:
- Fire extinguishers, medical gas shutoff stations and electrical panels are NOT blocked.
- No unsecured medications.
- Crash cart checks are all complete.
- Temperature and humidity parameters and positive and negative air pressures are correct (or if not, corrective actions are noted).
- Staff members are in correct surgical attire with hair covered and jewelry removed in semi-restricted and restricted areas.
“The trick is to stay in a continuous state of readiness to make sure required safety practices are in place every day, because there is no way to make sure all of this is in place after surveyors arrive,” Durkee advises.
He says focused and regular observation of staff, including by those who don’t work in the department on a daily basis can provide great ways to uncover areas for improvement and prevent survey day surprises. “Mock drills and random staff questioning on topics surveyors are sure to ask can also help staff feel more comfortable and confident when they are face-to-face with a surveyor,” Manderino adds.
“Any practice that will be scrutinized by a surveyor is also a practice that can prevent an adverse safety event that can not only impact the patient, but staff members, as well,” Durkee stresses. “Making sure to emphasize this focus on safety will help to instill adherence to safe practices among staff on a daily basis that will be evident on survey day.”
To learn more about how to prepare for these and other hot survey errors, including fire risk assessment as part of the Time Out, plan to attend Manderino and Durkee’s presentation on Joint Commission-CMS Survey: Continuous Readiness and Challenges in Perioperative Services Sunday, March 25 at AORN’s Global Surgical Conference & Expo in New Orleans.
Review your policies and procedures against the latest practice guidelines in AORN’s 2018 edition of Guidelines for Perioperative Practice.
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