Survey Date: - April, 2004
 
  Here are the admission unit/surgery/recovery room tracer and Competence 
 Assessment results from our survey that's wrapping up today. The nurse 
 surveyor was extremely friendly, supportive and appeared to be in more of 
 a consultative/teaching mode than I've ever experienced before.  She was 
 very accommodating with the new Tracer method and focused on interviewing 
 staff rather than management.  She realized that staff was nervous being 
 frontline and would continue asking a question in different ways if staff 
 didn't catch on right away what she wanted to know.  The Surgical services 
 manager and Educator were allowed to accompany the surveyor throughout 
 (except into the OR itself during the case) and there were things we 
 talked about as we worked our way through the system.  The rumor 
 circulated that they may send managers away and they wouldn't want us 
 around, but that wasn't the case (at least in our department).  Since the 
 surveyor actually went into the OR during the surgery, she was very 
 cautious to only observe and not distract the staff.  She only spoke with 
 them after the case was underway and there was a minor lull. 


 DAY 1, afternoon 


 Nurse surveyor came to OR, met staff. 
 Looked at schedule board to select her tracer patient for Day 2.  Only 
 stated criteria was a sided procedure.  Two possibilities were breast 
 biopsy and a hip replacement - she selected the THR, because she wanted to 
 witness our procedure for implant opening/documenting. 


 Asked whether the vendor would be here for the case, and if he handled 
 and/or opened the implant during a total joint. 


 DAY 2, morning 


 Arrived at 7 and changed into scrubs.  Was escorted to admission ward.  We 
 offered to let her look at the crash cart - she declined, saying she would 
 only be interested in it if the patient needed it in a code situation. 


 On admission ward, she spoke with the admitting nurse, asking for info 
 about the patient: 
         age? 
         what labs were done when? 
         allergies? 
         who/how was the surgical site marked? 
         who's with the patient now? 
         what's the patient's pain level now? 
         if you need blood, how does it get here - who goes to pick it up? 
 The admitting nurse said that she had already obtained the patient's 
 permission for the surveyor to be in the room for her surgery. 



 The orthopedic PA arrived, took the chart, and went in to see the 
 patient/update the H&P.  When she returned to the desk, the surveyor asked 
 her: 


         what's the rule for valid H&Ps? 
         do you do all of the ortho H&Ps? 
         how many other PAs work in the hospital?  where? 
         I'll be looking at your credentials - is that OK? 


 The surveyor (and surgery Manager) then went into the patient room to 
 introduce herself, explained why she wished to observed, confirm consent 
 and asked a few questions: 


         did she go through the preadmit process and how did that work for 
 her? 
         what preop teaching had she received both at the surgeon's office, 
 preadmit and from staff that morning? 
         she took note of the incentive spirometer at the patient's 
 bedside. 
         they discussed the benefits of hip replacement that will 
 facilitate returning to a higher quality of lifestyle. 


 They returned to the desk, and when the anesthesiologist arrived, she 
 watched him look through the chart. 


 The surgeon then arrived.  Surveyor was introduced and asked permission to 
 be in the room. (This was a bit of an issue, because our surgeons are very 
 serious about the "no observers during joints" policy.  In the end, he did 
 give permission with the stipulation that she stay for the whole case to 
 avoid an unnecessary opening/closing of the door.) 


 Surgeon went to talk to the patient, and the surveyor asked us about the 
 implant vendor: 
         does the vendor come for every case? 
         what was his orientation to the hospital? for instance, does he 
 know what a Code Red is and what to do? 
         who opens the implants in the room? 
         does he bring all the implants, or do you keep a stock? 


 Circulating nurse arrived, and together with the anesthesiologist went in 
 to assess the patient.  They invited the surveyor along.  When finished, 
 the circulator wheeled the patient to OR with surveyor along. 


 In operating room, the surveyor noticed/commented on: 
         introduction of patient to scrub nurse / side-site confirmation 
         "seamless" (her word) communication among staff 
         moment of pause 
         asked about the documentation of the moment of pause - "When do 
 you do it?  What do you document?" 
         asked circulator what was the biggest challenge she felt running a 
 total joint room 
         asked what was our usual turnover time 
         anesthesiologist handling/securing of medications 
         good process between Pharmacy and anesthesiology 
         fact that even though the vendor provided the requested implants, 
 all members of the surgical team "took ownership" of the process (i.e.: 
 looked at the box and verbally confirmed that was what they wanted) 


         circulator did the actual opening of the implants 
         aseptic technique (she knows it and was watching for breaks) 
         patient positioning & how our pre-positioning of the bias roll 
 (for the dressing) was ingenious 
         took note of the attention to the electrosurgical grounding 
 process 
         Neptune system for waste disposal 
         hand-off call (report) to PACU nurse 
         commented several times about the team work evident throughout the 
 process 

 In PACU, she first confirmed that a postop surgical note had been written 
 and mentioned she had already heard the surgeon dictate his note.  She 
 then focused on just one topic - when the post-op order called for a range 
 of medication dosages, how do you decide what to give?  Our policy states 
 that we should give the lowest dose in the range first, and if not 
 effective the next dose may be increased.  She said that what would be 
 better would be an order that stated (for example), "give 1 mg for mild 
 pain, 2 mg for moderate pain, and 3 mg. for severe pain" (since our pain 
 scale notes that "mild, moderate, and severe" are adjectives corresponding 
 to the numbers on the pain scale).  This will help standardize what 
 patients receive regardless of which nurse is caring for the patient.  She 
 said that for the nurse to just select & give a dose in the range could be 
 considered prescribing.   OUTCOME: Since our policy actually states to 
 start with the lowest dose and work up from there, she will not consider 
 this a finding, but will make it a "consultative recommendation" to change 
 our pre-printed orders to tie the dose to the patient's pain severity. 
 Since nurses are competent to assess patient's pain level, tying a 
 narcotic dose to a pain level is a logical process. 


 DAY 3, morning:  Competence Assessment process (Nurse surveyor) 


 Mostly HR, but educators were involved as well 


 Discussion session: 
         Asked about the process for bringing in new hires - how do you 
 recruit, what do you check, who does the interviews, who actually offers 
 the job? 


         How do you handle it when someone doesn't have the right attitude 
 but is great on skills? 
         Once hired, what's the process for orienting them to the hospital? 
 to the unit? 
         How do you assure competence when they arrive on the unit?  How 
 long does orientation take? 
         How is ongoing competence evaluated? 
         How compliant are you with getting annual performance appraisals 
 in on time? 
         How do you decide what continuing education the staff needs? 
         What data do you use to decide what to teach? (if one of your 
 responses is "the aggregate data taken from the reasons employees are on 
 corrective action", you'll be one up) 


 Employee record review - looked for: 
         Job Description 
         probationary performance eval 
         annual perf. eval. 
         credentials check (license, ACLS, PALS, etc) 
         continuing education / inservice records (looked for evidence of 
 education, but really wanted to see behavior evaluation - does this staff 
 member actually DO the thing you're teaching them?  Age-specific 
 competence, all aspects of patient safety, passing on thorough information 
 to the next care giver when handing-off patients, team work - working and 
 communicating effectively, recognizing and reporting adverse 
 events...these were some of the biggies). 


 ******* 


 My comment:  the usual staff comment pre-survey is along the lines, "I'm 
 going to be hiding when the surveyor comes around - I don't want to talk 
 to THEM!"  However, I've found that the greatest disappointment occurs 
 when the surveyor doesn't make it to an area.  For instance, she never 
 made it to CS, and they were very disappointed.  But with this new tracer 
 methodology, they only go to the "sharp end" - where the patient care 
 occurs.  Certainly if they find a problem (such as a rising post-op wound 
 infection problem), the CS department might get a visit to see if their 
 processes are adequate.  But when things work at the sharp end, it seems 
 their assumption is that the policies, procedures, and structures are in 
 place and working.  This is why managers aren't grilled as before - they 
 are much more interested in the staff at the bedside.  If THAT's broken, 
 then they'll work their way up to the dull end (policies, processes, 
 management, etc).  But if the care is good and no problems with process 
 are detected, there's no reason to read policies, look at logbooks, etc. 


 my 2 cents, 
 Diane Mathews, RN, MS, CNOR 
 OR Educator 
 Western WA