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You Want Me To Blog About What Now?
I’ve been blogging on The Patient Safety People blog for a while now, and I’ve covered a range of topics related to patient safety, document management, healthcare IT, and quality management overall.
These topics all stem from what I think you would like to know more about. But no one can tell me what you need to know better than you can!
So, please do offer some insight:
Best,
Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical
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Developing Education Material For Nurses
Orientation Day
Today I spoke to one of my colleagues who develops education material for new employees at hospitals.
As a quality professional, I learned so much from that discussion about what I don’t know.
We were talking about patient safety topics such as fall prevention and she shared with me all of the key pieces she would go over with new nurses. I went through some of the slides that she sent me and all of the content on the slides seemed to make sense to me, but then again, I knew the policies inside out, having helped write them with our fall prevention team.
That’s Just Not Right!
However, from an outsider perspective, the slides weren’t effective in reinforcing the “key issues” that we really wanted staff to know about our fall prevention protocol.
I asked her if she provided the employees with a hard copy of the protocol. She doesn’t; it would be too lengthy and they have so many other safety topics to cover during orientation day.
Precisely why she should have only the key issues in the slides!
My take on it is that it’s better for them to know the highlights than know nothing at all.
An Unsettling Idea
The reality of it is that nurses don’t want to dig through the content to find those key issues. And if they have to, they may not do it at all.
Countless times, nurses have told me that they want to go to the policy and quickly be able to find the one they need, with a concise breakdown of the information they’re seeking.
My experience when doing safety rounds is that staff don’t know the fall prevention protocol “key elements”. They also have not used the online policy intranet – so if we are expecting staff to learn our protocols, we need to be sure they can get to that information quickly.
So why not extract those “key issues” they’re looking for and put them into slides?
Well, she proclaimed that they are told that they can go to the intranet site, find the protocol and read the policy.
At this point, I expressed concern about the intent of the orientation – what is it that you really want new employees to know about certain safety topics? If you don’t have time to tell them all the key information, there is nothing wrong with summarizing key points and then referring them to the intranet. If you want to ensure that they do read up on it afterward, schedule a follow up with them in their 90 day probation period to see if they were able to find the documents on the intranet site, and go over the key information with them.
Taking Matters Into Our Own Hands
We are so quick to put information out there for nurses, but we don’t give them the opportunity to learn our systems – then we hold them accountable for errors made because they didn’t know our policy.
We need to look at things from a better perspective. What is our intent? What works for nurses? How can we get through to them? The key is to work with whoever is in your education department to make sure we’re all speaking the same language.
Orientation day is overwhelming enough as it is; it’s unreasonable to expect anyone to be able to digest anything more than just the key issues. My advice is to do everything in your power to make it easy for your new employees to get acquainted with your safety protocol.
Best,
Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical
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PolicyMedical is inviting you to join the newly-launched “Healthcare Policy Management Network“, the first LinkedIn group dedicated to policy management. The LinkedIn group is open to Quality, Patient Safety, Compliance, healthcare IT, nurses, and other healthcare professionals that have a hand the policy management of their healthcare facility.
Discussions Forum Moderator: me! I have years of experience in writing policies for hospitals, I’m a Certified Professional in Healthcare Quality, and I’m on the Joint Commission’s list of consultants that assist hospitals with certification and accreditation. I would love to channel my experience and expertise in answering questions posted in the discussions forum.
Open invitations to join this group will extend for another month. Please feel free to invite any healthcare professionals who would benefit from being a part of the network.
Join the Healthcare Policy Management Network here.
To give you a taste of the kinds of Q&A that may ensue in the LinkedIn group, I’ve posted a few from the past:
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Where can I go to find JCAHO requirement on pain management requirements?
Nancy Rodriguez
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Hello Nancy,
First let me address what, in general are the requirements on the topic of pain management: All hospitals, home care agencies, nursing homes, behavioral health facilities, outpatient clinics and health plans are required to embrace and thus incorporate the following concepts into their pain management programs:
• recognize the right of patients to appropriate assessment and management of pain;
• assess the existence and, if so, the nature and intensity of pain in all patients;
• record the results of the assessment in a way that facilitates regular reassessment and follow-up;
• determine and assure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff;
• establish policies and procedures which support the appropriate prescription or ordering of effective pain medications;
• educate patients and their families about effective pain management; and
• address patient needs for symptom management in the discharge planning process.
Your hospital Quality Management Director should be able to provide you a copy of the 2004 Joint Commission standards. Check The Provision of Care, Treatment and Services (PC) standards in the manual. The application of pain management is woven throughout the assessment, care planning and care delivery aspects of the provision of care and thus is referenced throughout these standards.
Nicola Heslip
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Does an MRI technologist have to be ARRT board certified to be JCAHO approved?
Terry Allen
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Hello Terry,
It is important to first understand that the Joint Commission does not survey “individuals” and thus staff members are not subject to being “approved” by the Joint Commission. An MRI Technologist does not have to be certified by ARRT unless your organization specifies such in the qualifications / experience section of their position description for this position. If you do specify that applicants and incumbent MRI technologists have an ARRT qualification, then you should hire only those so certified. Certainly, most imaging facilities in health care strive to have only ARRT certified staff caring for patients; it is a recommendation of the American Board of Radiologist, not a requirement by the Joint Commission.
Nicola Heslip
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Are hospitals required to have audiologic services available under the current guidelines and policies?
Caren Sokolow
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Hello Caren,
The short answer is no. The minimum number of health care staff members, both certified and non-certified is expected to be in accordance with State and local regulations. I am certain that your State has published its regulations and this information may be solicited from your Quality Management Director or directly from the State. From a Joint Commission perspective, they do not “mandate” that you hire an audiologist. They DO expect that your organization will examine the patient types being served and their needs and hire (or contract) the appropriate clinical and non-clinical staff to meet those needs of your patients. If the need for audiologist support services is internally justified, based on patient’s needs, then the hospital as an organization is to then determine the level of support (i.e. certified or not) is wishes to set as expected qualifications.
Nicola Heslip
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We are trying to find out the proper agency or commission to inquire if it is a law or policy that an employee of the hospital has to be licensed to scrub in on surgical procedures, example can a Patient Care technician, basically on the job trained person help in surgical procedures under the supervision of the surgeon and OR director. Can a CNA or Instrument Technician provide this service if trained by the department or surgeon to hold retractors etc.
David Ellis D.O.
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Hello Dr. Ellis,
Let me begin by saying that any/all matters relating to licensure requirements are generally mandated by the state in which you are providing care, the strictest being New York State and California. Thus the JCAHO does not mandate such qualification requirements directly – they do assess the hospital to confirm that they are complying with state regulations on matters relating to employee qualifications. In the absence of any state regulatory obstacles in your case, it is then reasonable to check with your own medical association, such as the AOA, for guidance on licensure and certification. It is feasible to have an “on the job trainee” provide a variety of support services, so long as it is written in their position description and their competency documentation. And that the individual is supervised and that person supervising them will document their performance as related to the procedures performed. HOWEVER, your question indicates that you are seeking then to assist in a surgical procedure by “holding retractors” and in my experience un-certified / un-licensed personnel are not permitted to actually engage in hands-on operative and/or invasive procedures.
Nicola Heslip
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We are trying to update our policy regarding NG Tubefeeding care, specifically, time recommended to change the bag and tubing. Our old policies are all based on the Lippincott manual, which gave very vague parameters, and the manufacturers will not set any specific recommendation. I know based on my own nursing experience and community standards of practice are: for acute setting, we change it every shift and for long term, every 24 hours.
My questions are: what is the specific recommended standard of practice for this care and based on whose recommendation?
Thank you for your attention & have a great day!
Maria Martin
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Hello Maria,
Like most organizations, we rely on the guidelines put forth by Lippincott. Nevertheless, if you click http://www.novartisnutrition.com/pdfs/us/presentations/Feeding_Tubes_Care_Section_Troubleshooting_guides.pdf you will find a full scope troubleshooting guide for a number of circumstances related to NG tubes. Specific reference is made to the timelines / circumstances for flushing that may factor into your proposed plans to amend your tube changing time frames.
Best of luck. I hope you have a great day as well!!
Nicola Heslip
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I am an anesthesia coordinator with an independent anesthesia group in the Los Angeles area. We employ CRNAs and MD anesthesiologists. Currently, we are working with a hospital that would like to begin using CRNAs. Does JCAHO have hospital policies and procedures for utilizing CRNAs? If not, do you know where I might locate current policies and procedures?
Naomi Benghiat
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Hello Naomi,
There are many questions within your questions! Let me begin by stating that the Joint Commission does not mandate specific “policies” for utilizing CRNAs per se. I say “per se” because in the hospital setting, “policy type information” relating to CRNA’s is generally contained within the MS Bylaws. The Joint Commission DOES focus on whether they are dependent CRNA’s (under constant supervision) or independent CRNA’s (practice independent of constant supervision). The relevance of this information is that both groups need to be incorporated into the hospital’s MS credentialing systems (initial appointment, reappointment, conform with the MS Bylaws, etc.). You will need to develop reliable ways to capture and report CRNA-specific performance data to channel into the CRNA performance profile to substantiate their reappointment each two (2) years. Capturing CRNA-specific data on a “dependent” CRNA is somewhat easier, as they are supervised and thus the supervising practitioner can often provide the performance data. Unsupervised CRNA performance data are more difficult to assemble; often chart review is appropriate.
Nicola Heslip
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I think this discussion forum will be beneficial to anyone who deals with policy management. I hope you join.
Best,
Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical
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I just got off the phone with a friend of mine.
She’s an RN in a physician office. We typically talk about how our day is going and when we can get together next to catch up.
Today though, I decided to ask her some questions about patient safety and what would be the things she would change if she had the chance.
She explained to me that she couldn’t really think of anything off the top of her head and said that she doesn’t have major patient safety issues as much as I would in my hospital since they are in a clinic setting.
I couldn’t help thinking to myself – I don’t think they’ve stopped to look at their vulnerabilities enough, since I see and hear about health care errors being made daily in outpatient/ambulatory settings.
So I didn’t stop at her answer.
I knew that in order to get some constructive dialogue going about this, I would have to probe deeper. I’ll sum up our conversation in paraphrased form:
Me: Do you have your policies and procedures online or in manuals.
Her: I think they’re online.
Me: Is it a system that’s easy to use?
Her: I haven’t been on there much.
Me: So when a policy is updated or is created, how do you learn about it?
Her: They usually send a memo out.
Me: Have you read the policies?
Her: I just skimmed over them.
Me: Is the information not valuable to you? Why don’t you read them?
Her: Well they are usually about what we can or cannot wear, and stuff we already know.
Me: So how is staff held accountable for reading the policies?
Her: There’s an employee handbook that is revised each year that we have to read on our intranet site.
I told her about the many themes that one can find in the patient safety literature but the one that stands out was the lack of communication between health care providers. She, of course, reassured me that they usually have means to find out what they need to know. Their method: the clinic manager sends memos out and keeps them up to speed on things.
Reactive vs. proactive environments
Based on her responses I thought about reactive environments vs. proactive environments.
Did the physician practice environment she described really have things nailed down from a patient safety perspective? Were the operational pieces and patient flow processes the causes of the majority of errors that could affect the patients? Who helps the clinic manager address patient safety? Is the clinic manager clinical? What can we learn from them, and what can they learn from us? Does the physician practice have their own IT staff? How do they keep up to speed on technology and patient safety initiatives to improve patient safety? Have they analyzed their policy and procedure system? How do they manage their documents?
Based on our conversation, these are just some of the questions that I still have for her. The next time we meet to catch up, I will surely follow up, and bare my thoughts on her responses!
Cheers!
Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical
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How Often Do You Audit Your Systems?
Perhaps you do so only when an issue is brought to your attention?
A more proactive approach would be to have an annual calendar with each key process impacting patient safety listed on it. Plan the schedule around budget review time. That way if you have a costly strategy in mind that will improve poor systems, you can plan accordingly. So what would you audit if you needed to provide leadership with the details of your intranet system? You could start with a survey for front line staff – the users of the intranet site.
Questions Might Include…
- How often do you use the system?
- Do you need assistance to get into the system?
- Is the system easy to use?
- Is navigating through the site easy or a challenge?
- Is the site helpful?
- Did you find what you were looking for?
- How long did it take you to find the policy/procedure?
- Do you like using the intranet site for policies?
- If you could change anything about the site what would you change?
- Do you feel comfortable sharing you comments with your manager?
The Importance of First-Hand Experience
It is important to personally visit the units while surveying the staff. Ask to attend a staff meeting and explain why you want to attend and what you’re hoping to learn from it. Sometimes leadership does not have the time or ability to make the business case and as a P&P or patient safety advocate, you can make the case yourself. It is up to you to bring that message from the staff to administration and to the CIO (IT) so that they can make a decision. In effect, you are, per se, a mediator and an advocate for the front line staff. Explain to the staff that this process of storing and accessing documents impacts the organization in many ways. The intranet site needs to be efficient and information needs to be accurate.
Seeking Out Champions
Seek out the staff that ask questions, as that is a red flag that they might want to be part of the task force for revamping, piloting and championing a new P&P application on their unit. Having staff participate in the idea of helping roll out and being part of a demo of something this big will empowering for them. Go to another unit and do the same thing. It is so important to really look at systems to see whether they are working as they were intended.
Plan Do Check Act
Rolling out is not the end all be all. The model for change, performance improvement is PDCA (plan do check act). All of this is simply the “checking” stage. Based on what your survey findings are, you can then develop an action plan. And don’t forget to bring those unit staff champions with you! The leadership team needs to hear from them too.
Managing an intranet takes a lot of work and hospitals don’t have the funds to maintain a large IT support service. It is time to find out what will work for your staff, improve patient safety, and then act on it!
Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical
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The Disconnect
Too often, I have experienced a disconnect between healthcare IT departments and the Quality/Patient Safety departments within those organizations.
A hospital is a large entity made up of complex systems. Within those complex systems are smaller subsystems, and so on. The entire hospital can be affected by what happens or doesn’t happen in those subsystems since all of them are interconnected as a web and altogether make up the whole.
In our daily operations, we are used to living in our “silos” and it is only when the outcome we get is not expected do we really look outside our silos and work collaboratively to solve the problem.
Case Study
An example that I’ve personally experienced was when a nurse expressed her concern that the department printer she used for obtaining medical record information was too far from the wing in which she was stationed at the hospital. Each time she needed to print anything for the patient record, she had to leave her patient, walk through the secured double doors down the hall about 75 feet to the closest printer to retrieve the document, and then walk back with it before proceeding with patient care.
Was the document important enough to have to go to that trouble? The answer: absolutely yes. The information on the form was obtained upon the patient’s admission and was vital for the nurse to be able to assess the condition of the patient, and to keep the patient’s medical history up-to-date.
It was great that their IT system had built the form and that the hospital’s system had data dumping ability. ADT feeds are great and automating documents for nurses is so crucial for saving time. The problem was that in this case, the nurse’s department did not have its own printer. The new space that they were in was not configured for a printer. At the time that the space was designed, IT had not yet developed the automated form, and so nobody thought to ask how the staff would get it.
The Investigation
When I came in, I took a look at the entire process and the potential risk to patients. Often, only two nurses were on the floor at the time, so changes were good that at any given time, one of the nurses would have to leave the entire wing of patients alone in order to obtain a printed document. I asked the overseeing manager about the flow and mentioned the concerns from staff and it was agreed that the current set up could be improved.
Apparently, IT was notified many times that another printer was needed. The nurses in the department voiced the need to IT, but did not explain the rationale behind the need. The IT department felt that the nurses were calling to complain, and thus the rift between the two departments was created. For the longest time, IT did not get a printer because of other priorities and other conflicting projects, and as usual, budget was also a reason to hold off unless the need was deemed to be “urgent”.
The Solution
When I mapped out the aforementioned department’s flow and current system and met with IT, I explained the department’s need by providing an scenario to give the issue some context. Imagine if your mother was admitted into that department of the hospital and needed to be attended to at all times, but nurses were going in and out all day, often leaving her alone in order to go get the electronic information from a printer 75 feet away. This context definitely helped IT understand the urgency and importance of establishing the infrastructure. The IT staff stated that if they had known the context of the need, they would have made it a priority. In addition, they said they had appreciated the “data” and process mapping that was done to help them prioritize and be able to justify costs proceeded to drop other projects to meet the staff’s needs. Immediately, a call was made to get create an outlet and soon, another printer was installed in that department.
The Takeaways
This incident helped the front line staff understand and appreciate how critical IT’s role is to improving patient safety. It also demonstrated how important it is to work with Quality/Patient Safety staff in the planning phases as projects are being initiated.
Currently, at this hospital, the nurses are satisfied that their concerns were heard and attended to, and that less time and money is being wasted with staff scurrying to get documents. Most importantly, they’re glad that their patients are getting the safe care they deserve.
Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical
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4 Ways To Overcome Technical Challenges as a Nurse
Technology Is Here To Stay
During the last decade, we have seen an increase in the use of computer technology in healthcare. Whether you are at the registration desk of a dental office, doctor office or on the unit in a hospital, or even at “check-in”, you will need something scanned or swiped.
This Is Why I’m Concerned
Recently, as a patient, I experienced the challenges of having to rely on computers to receive the care I needed. At the registration desk, there was a 10 minute delay. No, it wasn’t that my insurance card was outdated or that I had to sign my annual update for HIPAA. I found out I had two account numbers in the system! They had to sort out that mess.
Of course, many thoughts came to mind. How did this happen? Why was it not caught sooner? What information is in what account? Will this affect other appointments I have down the road? The patient service attendant who had many years working with the technology claimed it was a glitch.
Later in my stay, when it came time to scan my arm band prior to giving me my medication, the nurse appeared to be confused, wearing a puzzled look on her face. She had to clarify the order showing in the system. This meant waiting 20 minutes for my pain medication. The nurse appeared frustrated and told me that she had only worked there a month, and was not used to our “system”.
The Double Edged Sword
Yes, technology can prevent patient harm but at the same time, glitches and user incompetency can impede the care we need.
Many nurses who have been in healthcare a long time have had to learn “on the go” and have had to adapt to the changes in – for examples – documentation, computer physician order entry (CPOE), or electronic medication administration records.
When speaking to some of them in person during my safety rounds, I am surprised to hear how many do not have computers at home and only use one at work. I also have seen the challenges with on-line incident reporting. Some staff even expressed to me that they avoid completing the event report because they are not familiar with the fields in the database and don’t want to make a mistake. What about online policies and procedures? I certainly hope that nurses aren’t not using them because the technology is intimidating to them!
4 Ways To Improve Technical Competence
Multi-Site Hospital Systems Can Learn From SurgiCare
On May 26, 2010, I was lucky enough to visit a new client of ours – SurgiCare Inc. They have been around for 30 years but they are still innovating and growing at a rapid pace. They are slightly different from our hospital clients in that they are a chain of centers that perform surgery, as well as provide braces, prosthetics and other devices to help with rehabilitation and recovery.
If there was one key take away that multi-site hospital systems can learn from an innovator like SurgiCare, it’s the following:
During my tour through their headquarters, I was taken through an area that housed systems and staff for patient billing, human resources, patient support, etc. What SurgiCare Inc. had done was centralize as many overhead business processes as possible at their headquarters. This leaves their surgery centers to focus on what surgery centers should – delivering quality service to their patients. Simple, yet brilliant.
I have been in many multi-site facilities over the past decade, and time and time again, I see duplication of staff, systems, and processes. This leads to too many layers, which ultimately translates into patient and staff frustration.
Not the case at SurgiCare.
Saud Juman | President | PolicyMedical
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10 Tips For Writing Policies Staff Will Read
Why Spend All That Effort Writing Policies?
Why spend all that effort meticulously drafting policies and procedures if no one is going to read them?
During my visits to nursing units, I always make a point to ask the front line staff about the tools they have to do their job well.
What hinders you?
What would make your job easier?
What do you see as being wasteful and purposeless, yet incredibly time-consuming?
A Common Theme To The Responses
A common theme to the responses that I hear is that inefficient document flow and paper shuffling wastes time. To make it worse, the policies and standards of care are often not even read.
“Why does staff avoid accessing policies and reading them?” I ask.
I hear answers like:
“They are too long”
“I have difficulty finding what I am looking for, since it is buried in all the text”
“The content is outdated and references are not even current or follow best practices”
An Important Fact That’s Often Overlooked
It is important that the staff in your organization have the opportunity to give feedback about the policies and procedures they use every day. It makes sense to ask them. When you take your car to the service station, they ask you to complete a survey about your experience using the car, right (or at least, they should!)? The most important people to ask about any process should be the very people who use it, yet this point is often overlooked when evaluating processes.
2 Out Of 5!
Staff nurses have told me that they rate the effectiveness of P&Ps at about 2 out of 5 – they’re simply not satisfied with the way the policies read, so they don’t want to consult them as guidelines. They just trust their head knowledge and ask their peers about what to do, rather than using the policy which is not safe at all.
How do you improve on that score of 2 out of 5?
Adopt Some Key Principles of Writing Good Policies
On the internet, there are many tools, guides and handbooks for writing them.
Here is a brief tutorial: the policy and procedure format should be simple, standardized and easy to use. For a not-so-brief tutorial, download the guidelines that I’ve provided below. Look at the policies in your facility, and see if they follow the 10 qualities of good policies.
Download the 10 Qualities of Good Policies
Included in the download is a recommendation for how your policies should be formatted.
Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical
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Banfield Hospital: Aiming for Purrfection
For the last several months I have had the pleasure of working with the folks at Banfield The Pet Hospital. For those that are not familiar with Banfield, they are one of the largest chains of pet hospitals out there (approximately 750 hospitals). In my work with PolicyMedical we have been providing our solutions that have made human patients safer for the past decade. Needless to say I have been extremely excited to have Banfield onboard because we now help to make animal patients safer.
I’ve just spent a day with the folks at Banfield at their head quarters in Portland, Oregon. And I have to say, I am inspired! Inspired from their winning culture. I’d like to point out some of the things that have stood out in my mind from my Banfield visit, with regards to how it impacts patient safety:
1. Hiring employees/talent that fit with the culture. At Banfield, everyone either has a pet or loves animals. This ignites passion and creativity in their work and incents them to look out for the best interest of the hospital.
2. Being really good to your people. Banfield recently moved into headquarters that was architecturally beautiful and simple. Everyone has lots of light, great working conditions, a lean physical design that fuels collaboration, access to delicious and healthy food, as well as an onsite fitness center. You can just tell that this helps Banfield’s talent to be that much more productive and tuned into the best interest of their patient’s safety as they themselves are healthy and happy.
3. Having simple, honest & outstanding values. In the room I spent most of my day in there was a large plaque that had Banfield’s values. One of the values spoke about freedom and specifically the freedom to do what Banfield wants to do to continue to WOW their patients. Included in this particular value statement was the idea that they must always be profitable to continue to have freedom. This simple and honest idea is not admitted at most organizations. But it is true – a profitable environment where the facility is free to do what it feels is best for its patients is ultimately an innovative and safe environment.
4. Walk the talk. As everyone at Banfield loves animals, employees are allowed to sign-up on a schedule to bring their pet (usually a dog) to work with them. This is done in a very orderly way. All of the dogs I saw at Banfield were relaxing calmly as their owner was working away at their desk. However there is always the option to take your dog out to the large dog park that is constructed in front of the building for employees as well as residents of the local area.
A winning organizational culture where all employees TRULY buy into the MVV (mission, vision, values) will naturally trickle down to your patients, providing them with an amazing quality of care and safety.
Saud Juman | President | PolicyMedical
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