Download When multiple disease- specific care surveys arrive

October 2009 Vol. 20, No. 10
When multiple diseasespecific care surveys arrive
“Disease-specific care has been functioning for many
years, and it acts as a mark of excellence,” says ­Elizabeth
Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare
consultant in Trabuco Canyon, CA, and former Joint
Commission surveyor.
After reading this article, you will be able to:
➤➤ Describe similarities and differences between full surveys
and disease-specific care surveys
➤➤ Discuss educational requirements from disease-specific
For Main Line Health, a six-hospital system outside
of Bryn Mawr, PA, this meant four surveys in three hospitals from February through August. However, with
the right prep work, four surveys in a six-month period
was not cause for panic, says Mary McKay, RN, MS,
care surveys
➤➤ Identify how education and leadership tie together in a
disease-specific care program
CPHQ, system director of regulatory
affairs and nursing
On the upside, disease-specific care (DSC) certification
surveys provide a little more notice for hospitals than triennials because The Joint Commission announces surveys six to eight weeks in advance rather than arriving
quality. The system weathered a
ventricular assisted
device (VAD) destination therapy
unannounced. On the downside, in a six-hospital system
program, primary
with multiple DSC programs, those surveys can arrive
stroke center cer-
uncomfortably close together.
tification, and two
“What makes you
different? What sets you
apart from the hospital
down the street?’ That’s a
message we hadn’t seen in
print before, and it really
drove the message home,
to refine the program and
give it a unique look.”
— Mary McKay, RN, MS, CPHQ
knee and hip programs successfully in a matter of weeks.
IN THIS ISSUE
p. 4 CHF discharge instructions
Two hospitals share best practices for
educating patients about their illnesses
to help cut back on readmissions.
p. 8 Greeley survey solutions
WendySue Woods, RN, MHSA, CSHA, takes on the challenging issue
of updating hospital policies, with a humorous look back at historical
contexts.
p. 9 Root cause analysis
Guest columnist Robert J. Latino, CEO of Reliability Center, Inc.,
examines error prevention and root cause analysis.
p. 11 Dietetics tracers
Advisor Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, explores
dietetics and food services tracers through the lens of CMS’ Conditions
of Participation.
The prep work for a DSC survey is similar to preparations for The Joint Commission’s triennial survey, says
McKay.
“It’s very similar—you do your annual Periodic Performance Review (PPR) and take your action plan from
that,” she says.
Main Line Health is also part of the ContinuousSurvey Readiness program, which provides a self-assessment
similar to the PPR. Each program underwent a self-­
assessment, devised action plans, and brought in clinical
leaders to help push for improvements.
“With these certifications, the closer you get to the
clinical area, the more robust the program is going to
be—you’ll have a better sustainability and compliance,”
> continued on p. 2
Briefings on The Joint Commission
Page 2
Surveys
October 2009
< continued from p. 1
says McKay.
want to know you’re addressing patient safety. Don’t
In the weeks leading into the surveys, mock surveys
lose sight of those.”
were conducted internally or through a consultant.
“Six to eight weeks before the survey, we have our
own internal tracers we conduct, focusing on those areas
Surprises?
Surveyors were very interested in education dur-
impacted by the program,” says McKay. Stay vigilant in
ing DSC surveys, McKay notes. “One quote all of the
all areas before the surveyors arrive, she says.
surveyors used: ‘What makes you different? What sets
“One caution: Don’t ignore the rest of the patients
you apart from the hospital down the street?’ ” she says.
or the rest of the unit,” says McKay. “You know they’re
“That’s a message we hadn’t seen in print before, and it
coming in to survey you for stroke or knee and hip, but
really drove the message home, to refine the program
it’s still important that all of your admission assessments
and give it a unique look.”
are complete. Nutritional, pain screening, falls ... they
The education component is more prescriptive in some
programs than others.
Editorial Advisory Board Briefings on The Joint Commission
Group Publisher: Emily Sheahan, [email protected]
McKay. “Each staff was asked, whether they were nursing
Senior Managing Editor: Matt Phillion, CSHA
[email protected],
781/639-1872, Ext. 3742
or therapy or anyone else, what additional training you
Contributing Editor: Jodi Eisenberg, MHA, CPMSM,
CPHQ, CSHA
Program Manager, Accreditation
and Clinical Compliance
Northwestern Memorial Hospital,
Chicago, IL
Editorial Assistant: Sarah Kearns,
[email protected],
781/639-1872, Ext. 3298
Steve Bryant
Vice President and Managing Director
The Greeley Company
Marblehead, MA
Joseph Cappiello
Chair and CEO
Cappiello & Associates
Elmhurst, IL
Elizabeth Di Giacomo-Geffers, RN,
MPH, CSHA
Healthcare Consultant
Trabuco Canyon, CA
Lori Hagen, RN, CPHQ
Patient Safety Manager
James H. Quillen VAMC
Johnson City, TN
Bud Pate, REHS
Vice President
Content and Development
The Greeley Company
Marblehead, MA
Geri Pyle, RN, MS
Healthcare Consultant
Palm Springs, CA
Diane Rogier
Former President
National Association for
Healthcare Quality
Glenview, IL
Paula S. Swain, MSN, CPHQ,
FNAHQ
Swain & Associates
Healthcare Improvement
and Compliance Consulting
Charlotte, NC
Briefings on The Joint Commission (ISSN: 1941-5877 [print]; 1941-5885 [online]) is published monthly by HCPro, Inc., 200
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“With stroke, there’s a big education requirement,” says
had in this area. And whether you’re looking at stroke or
knee and hip or VAD, that education sets you apart.”
Staff education also reflects on the hospital as a whole.
“From the surveyor’s point of view, they ­also want to
know that having this additional education shows leadership’s commitment to the program,” says McKay. “Education is part of the organization’s goals.”
For its knee and hip certification program, Main Line
Health had developed an individual care plan for patient
education.
“Folks come in with a preop visit, and that education
follows them through their hospital stay,” says McKay.
“Postdischarge there’s a chance to participate in further
education.”
The organization was able to demonstrate the content
and initial education to the hip and knee patient and
document the patient’s understanding, which reflected
well on the program during the survey.
Patient education was one area in which the stroke
program received an RFI. Although the education was
being provided, documentation of such education was
lacking.
“We use nursing pathways and we haven’t gone fully
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Briefings on The Joint Commission
October 2009
Page 3
electronic yet,” says McKay. “Because we use prepopu-
were age-specific, which are passé,” says McKay.
lated pathways, they were not specific enough for stroke
“We are moving to population-based.” Although the
education.”
system has done well on past surveys, it knows that,
Although the surveyor saw and believed that the fa-
having gone through four DSCs, the competencies
cility was performing the appropriate level of education,
will need to be updated for the next triennial survey
the generic template for documenting this education will
and for DSC recertifications.
be improved.
➤➤ HR files. “We were surprised at the number of HR
That being said, the programs performed remarkably
files they pulled,” says McKay—or rather, the lack
well during the surveys. Two of the four programs came
thereof. For each of the surveys, fewer than five HR
away without a single RFI, and the other two programs
files were requested.
had only two findings each.
A lot of the success of these surveys came from the
excellence of Main Line’s staff education component.
“I have to give kudos to our nursing staff educators,”
says McKay. “I think the challenge will be in sustaining
this going forward, always remembering this population of the staff needs more than the mandatory training sessions.”
How do they compare?
The surveyors were extremely personable and offered a great deal of guidance and education, says
­McKay, leaving behind helpful tools for improving
processes.
“We have that sort of back and forth during the triennial, but there’s a more personal aspect to the DSC sur-
Recertification?
The second time around should be a very different experience, says McKay. “I’m looking forward to the recertifications,” she says. “I think in some ways, as we know
now what to expect, they’ll be easier.”
Main Line Health has already begun identifying areas that will be a challenge prior to the next round of
surveys. First and foremost will be tracking standards as
they change—the “unknown” factor between surveys,
veys,” she says.
In terms of workload, the more focused nature of a
DSC survey, although intense, is in many ways more
manageable. Issues that arise tend to be program-specific
and not systemwide.
Systemwide issues can occur, however. A hypothetical:
In 2008, The Joint Commission changed its standard for primary source verification. Even if a hospital changed its process, it needs to verify that such a change is implemented
McKay says.
Also, tracking new staff members and the necessary
correctly and sustained. If even one clerk does not imple-
education will be pivotal. “As you acquire new staff,
ment the change and continues to operate under the old
you have to have [process(es)] to capture their data, put
standard, this can affect the whole system when it comes
them into the pipeline for ongoing training and educa-
time for survey.
tion,” says McKay.
Several unexpected points came up before, during,
and after the survey:
What’s next?
Main Line Health is not done with its DSC surveys
➤➤ Clinical competencies. “For these units, they need
yet. The remaining facilities are still in the process of set-
particular competencies that are going to speak to
ting up initial certification for knee/hip programs, stroke,
how they are competent, what sets them apart from
and COPDin the next six to nine months. After that,
nurses on an adjacent floor,” McKay says.
the organization will be looking at the first rounds of
➤➤ Older competency policies. “Our competencies
© 2009 HCPro, Inc.
recertifications. n
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Briefings on The Joint Commission
Page 4
October 2009
Best practice
The many variations of CHF discharge instructions
When patients come into the hospital with an illness
needed to manage their disease after discharge,” says
or health problem, staff members must do all they can to
Miller. “One of the quality initiatives was to prevent
help patients improve during their stay. Staff members
readmission.”
must also ensure that patients take care of themselves
upon leaving to prevent a rehospitalization.
Congestive heart failure (CHF) is a health problem
that requires special care and follow-up for patients.
Dickinson County Healthcare System (DCHS) in Iron
Mountain, MI, and Smithville (TX) Regional ­Hospital
SRH provides weight monitoring calendar
Although the CHF instruction sheets at both facilities are designed to educate patients as they leave the
facility as well as prevent readmission, there are some
differences.
(SRH) each decided to revamp their CHF discharge in-
SRH’s CHF instruction sheet was developed in 2005,
structions to help avoid CHF patient readmission. As
right as Miller came on board in the quality management
a result, both facilities saw a drop in their readmission
department.
rates and a general acceptance of discharge instructions
from patients and staff members alike.
One of the main reasons for developing the instruction
sheets was the fact that the facility did not have electronic
medical records.
Common ground shared between facilities
Along with preventing readmission, both facilities wanted to improve their compliance with CMS requirements and make improvements to their quality
initiatives.
“Nurses would forget to document whether or not they
had educated the patient on weight monitoring and basic
follow-up information,” says Miller.
The two-page Patient Information on Heart Failure
document (see p. 6) was developed using resources from
However, prior to each facility deciding to revamp
their CHF discharge instructions, Jeanette Parent,
the TMF Health Quality Institute, formally known as the
Texas Medical Foundation.
RN, nursing education coordinator at DCHS, and Julie
On the first page is a list of symptoms to watch for
­Miller, RN, quality director at SRH, each received infor-
when patients return home. These symptoms may indi-
mation to help them take that initial step toward devel-
cate that a patient’s CHF is worsening and that he or she
oping the instructions.
should contact his or her physician.
Parent says the review analyst team at DCHS found
At the bottom of the first page is a line for the patient
that the facility was consistently failing the written dis-
to sign and date. Once the patient has signed, one copy
charge part of Core Measure Standard #1 for CHF.
goes into the patient’s records and the other is sent home
Based on this finding, Parent and other staff members
at DCHS set out to develop the discharge instructions to
help comply with this standard.
Meanwhile, Miller says her facility didn’t necessarily see
with the patient.
The second page of the CHF instructions focuses on
weight monitoring.
“Due to the fact that CHF can cause the patient’s body
an increase of readmissions, but it did see a potential for
to retain water, it is important that the patient weighs
increase based on evidence-based standards referenced by
themselves regularly,” says Miller.
CMS’ Quality Initiatives.
“We developed the patient teaching sheet to assist
us in making sure the patients got the information they
© 2009 HCPro, Inc.
The instruction sheet provides three calendar sheets
where patients can monitor their weight and get in the
habit of doing it every day.
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Briefings on The Joint Commission
October 2009
Along with the CHF discharge instructions, patients
Page 5
“The case manager noticed that we were seeing one or
were also given instructions on when to follow up with
two patients with three to four admissions over several
their doctor. The follow-up appointment varied, depend-
weeks due to noncompliance,” she says.
ing on the individual patient. It could range anywhere
from three to seven days.
To help prevent this from happening, the case manager worked with the cardiac rehabilitation manager
to provide ongoing education for patients discharged
DCHS’ checklist and follow-up phone calls
At DCHS, the CHF discharge instructions are slightly
different.
with CHF.
As part of this ongoing education, an RN from the cardiac rehabilitation center was tasked with calling each pa-
DCHS’ heart failure document was developed in
tient at home. The RN would ask patients whether they
2004 after the facility failed Core Measure Standard #1
were taking their medication, what their weight was, and
for CHF, which addresses discharge instructions and pa-
how they were feeling. The RN would also send educa-
tient education.
tional material to CHF patients every week for six weeks.
DCHS felt that nurses were educating patients but
failed to document their teaching.
Parent and a team consisting of the review analyst, the manager of medical and ICU, representatives
from nursing education, and the case manager, devised
Physicians were somewhat reluctant in the beginning
because they thought they were giving out too much
information.
“In the end, we were able to sell our views,” says
Parent.
the Heart Failure document that is distributed to CHF
Results and acceptance
patients.
“We give any inpatient that has the diagnosis of CHF
After implementation, SRH patients were receptive to
as their principal diagnosis and/or has a secondary diag-
being educated on their disease, and the doctors found
nosis a teaching sheet for CHF,” says Parent.
the CHF discharge information to be helpful because pa-
The one-page teaching sheet lists the definition and
symptoms of CHF as well as general information about
tients were ready with the information, says Miller.
The CHF discharge information has been so well received that SRH has begun development of similar
the disease.
The general information portion of the teaching sheet
includes instructions for patients to follow when they return home. Some of these instructions ask CHF discharge
patient education forms for patients diagnosed with
pneumonia.
At DCHS, patients and their families really liked the
patients to:
instruction sheet because they were able to return to it
➤➤ Weigh themselves daily in the morning, on the same
as a reference, says Parent.
scale, wearing similar clothing
➤➤ Avoid drinking softened water—salt is used to ­
When asked what they would do differently, Parent
and Miller both said they would get the nurses more involved next time around.
soften it
➤➤ Limit intake of caffeine and alcohol
“Nurses can bring you real-life experiences,” says
➤➤ Keep regular physician appointments
Miller. “They have worked with the patients and can
➤➤ Check pulse prior to and after taking medications
tell us what works best for them.”
such as Digoxin/Lanoxin
“Include your staff more; once they have an understanding of why we need them to review yet ­another
Parent says even after DCHS initiated this teaching
sheet, it was still seeing repeat readmissions.
© 2009 HCPro, Inc.
piece of paper with patients, they jump on board,”
­Parent says. n
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Page 6
Briefings on The Joint Commission
October 2009
Patient Information on Heart Failure
© 2009 HCPro, Inc.
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October 2009
Briefings on The Joint Commission
Page 7
Created by Smithville Regional Hospital, Smithville, TX. Reprinted with permission.
© 2009 HCPro, Inc.
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Briefings on The Joint Commission
Page 8
October 2009
Prudence or wisdom? Can your policies pass muster?
another. Many organizations divide the policies, which
are often reviewed and revised by people who do not
After reading this article, you will be able to:
have firsthand knowledge of the process. Others may
➤➤ Identify ways of preventing “work-arounds” by the staff
choose to accomplish this by committee, which results
➤➤ Discuss “tagging” policies
in policies being revised without the input of those who
➤➤ Describe ongoing education needs to maintain staff
must comply with the policy.
member compliance with hospital policies
Approximately 5% of The Joint Commission’s elements of performance (EP) are frequently cited. These
Editor’s note: WendySue Woods, RN, MHSA, CSHA, is a
are the Joint Commission EPs and CMS requirements
senior consultant at The Greeley Company, a division of HCPro,
that have the seemingly greatest effect on an organiza-
Inc., in Marblehead, MA. Each month, an expert from The
tion’s ability to consistently deliver quality and safe care.
Greeley Company will discuss a hot-button topic or challeng-
­Consistency is key, and this can be driven by a successful
ing issue facing hospitals in the areas of accreditation, survey
policy and procedure review process.
preparation, and more. Have a question for our experts? E-mail
Matt Phillion at [email protected].
Organize your policies
➤➤ “Tag”—you’re it. When developing or revising a
In 1751, Dr. Thomas Bond and Benjamin ­Franklin
policy, “tag” that policy with the corresponding Joint
founded the first hospital of the 13 colonies. At that
Commission standard and EP as well as creating a
time, Philadelphia was the fastest growing city, boast-
link to the CMS Conditions of Participation “A” Tag.
ing a population in 1730 of 11,500 that grew to 15,000
Once you have this set up as a system, as require-
in 1750. The mission of Pennsylvania Hospital, as it was
ments and regulations are updated or change, it is
then known, was “to care for the sick, the poor, and the
easy to find the policy or policies and make the nec-
insane who were wandering the streets of Philadelphia.”
essary changes.
Patients were expected to follow strict rules and poli-
➤➤ Practice = Policy. During the revision or review
cies. They had to comply exactly with orders given by
process, take the policy to the bedside. Talk with staff
physicians and nurses. There was no talking allowed on
members about the requirements and the methods
the wards when the physicians were present. Patients
they are currently using. Identify shortcuts that staff
could not be in the bed unless they were in bedclothes—
members have developed. Sometimes these are rea-
no street clothes were allowed. There was to be no pro-
sonable and still maintain compliance. Other times,
fane language, gambling, or spitting on the floors. And
these shortcuts can lead to missed steps, resulting
my personal favorite: If you were able, you were expect-
in noncompliance. Take time to talk with your staff
ed to help the nurse with her duties.
to understand why the shortcuts or “workarounds”
Imagine updating those policies to match standards of
practice today?
were implemented and help keep the process sensible
to the end user. This will ensure compliance and consistency. Practice will match policy.
Don’t just go through the motions
Organizations have developed processes to ensure
➤➤ Keep it simple. Policies that are created from textbooks or in isolation can often create ­unreasonable
that policies are reviewed and revised as appropriate.
expectations of the end user. Implementation of
This practice can vary greatly from one organization to
the policy when put into practice and placed ­under
© 2009 HCPro, Inc.
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Briefings on The Joint Commission
October 2009
Page 9
scrutiny can result in noncompliance because the
This piece of paper is only as good as the end user’s
steps did not make sense and, therefore, were not
ability to consistently comply with the requirements
followed. Keep the process simple. Review the
and demonstrate competence.
minimum expectations and align the policy accordingly. Just because something sounds good on paper does not mean it can be easily and consistently
accomplished.
➤➤ Take it for a test drive. Once a policy has been devel-
258 years later
If you were one of the lucky ones setting up the first
hospital in the United States, you would have been writing the rules from scratch. That groundwork has long
oped or reviewed and revised, take it for a spin. Think
been established, but there are guidelines that can serve
about what it would have been like to test the policy of
as valuable resources. A chapter in the 2009 Comprehen-
“no talking when the physician is on the ward.” How
sive Accreditation Manual for Hospitals (CAMH): The Official
could patients communicate their needs? How would
Handbook, “Required Written Documentation,” provides
the nurse have discussed the patient’s condition and re-
a list of all of the Joint Commission EPs requiring written
sponse to treatments? Make sure the steps outlined in
documentation for hospitals. Not all of the items listed
the policy make sense to the staff members who will
require policies—many are references to logs, ­licenses,
need to ensure implementation. Only then is the policy
annual reports, etc.—but this is an excellent starting
ready for the stamp of approval.
place for the prioritization process.
➤➤ Educate and assess. Once the policy has been de-
However your organization manages the process of de-
veloped, reviewed, or revised and you have taken it
veloping, reviewing, and revising policies, invest the time
for a test drive, your work is not done. Ensure that
to evaluate it to ensure it can pass muster. Your process
your staff is educated or reeducated on the policy and
should give you the confidence that your patients are con-
any changes or nuances that need to be discussed.
sistently being provided safe and quality care. n
The value of root cause analysis
Editor’s note: This month’s guest columnist is Robert J.
industries. I am a practitioner, educator, author, and de-
­Latino, CEO of Reliability Center, Inc., and an expert in root
veloper of software tools to aid in more extensive and
cause analysis.
accurate investigations.
Latino regularly blogs on the topic at www.­reliability.
To this end, I would like to relay some highlights of
com/industry/training/rca_blog.html. He can be reached
my findings from hundreds of root cause analyses (RCA)
at [email protected] or 804/458-0645, or you can visit
that I have been involved with to various degrees in both
the Reliability Center Web site at www.­reliability.com.
industry and healthcare:
1. No matter the industry, failure occurs most often be-
I would like to present the perspective and opinion of
cause people make inappropriate decisions to do or
someone who has come from the high-tech industry and
not do something (i.e., errors of commission or omis-
has spent the past 12 years in healthcare. It has been in-
sion). People usually make these decisions with good
teresting to contrast the two worlds.
intent; however, the basis of the decision is made
I am an expert in investigating undesirable outcomes
regardless of the industry. I base my observations on 25
years of experience in the manufacturing and healthcare
© 2009 HCPro, Inc.
with poor information. These decision errors are
what we refer to as human root causes.
> continued on p. 10
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Briefings on The Joint Commission
Page 10
Root cause
October 2009
< continued from p. 9
2. This poor information comes from deficient or non-
➤➤ Lack of accountability system (e.g., responsibility with-
existent organizational systems (e.g., policies, pro-
out accountability, normalization of deviance, no nega-
cedures, procurement practices, or training systems)
tive consequences for poor decision-making, etc.)
that are supposed to provide us with proper informa-
➤➤ Distractive environments (e.g., missed steps in a se-
tion to make educated decisions. These systems issues
are what we refer to as latent root causes.
3. Poor decisions result in unintended physical consequences (e.g., wrong meds dispensed, paperwork
filled out improperly, or delays in handling blood),
which if not caught, will eventually result in patient
harm or a close call (i.e., high risk). These observable consequences are what we refer to as physical
root causes.
quence, slips, lapses, mistakes, etc.)
➤➤ Work stress (i.e., leaner staffing, more patients, more
failures, increased stress at home from economy, divorce, etc.)
➤➤ Overconfidence (i.e., “I’ve done this 1,000 times
before”)
➤➤ First-time task management (e.g., agency people,
new hires)
➤➤ Imprecise communications (i.e., top to bottom, lateral, between departments, language barriers, etc.)
To summarize: Undesirable outcome - physical roots human roots - latent roots.
➤➤ Vague/incorrect guidance/procedures (e.g., obsolete
policies and procedures, vague compliance require-
If we correct the systems, we will correct the decision
behavior and thus the string of undesirable consequences
will not occur.
ments, conflicting requirements from management,
etc.)
➤➤ Lack of training (e.g., inservice, on new technology,
The following are the major categories of latent root
causes that we have found in our hundreds of analyses
on new procedures, on new regulations, etc.)
➤➤ New technology (i.e., no training provided, no new
over the past 25 years:
procedures put in place, preventive maintenance not
➤➤ Ineffective supervision (i.e., being more aware of the
kept up, etc.)
poor decision-making of subordinates, work sampling,
credentialing, and so on.)
No matter where you work, we all work in systems
➤➤ Time pressure (i.e., encourages shortcuts to be taken)
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Briefings on The Joint Commission
October 2009
Page 11
Standard of the month
A look at dietetic/food service standards and CoPs
What policies are required? According to CMS’ CoPs,
your facility should have and follow, at minimum, the
After reading this article, you will be able to:
following policies and procedures:
➤➤ Identify Joint Commission chapters addressing dietetic
➤➤ Availability of a diet manual and therapeutic diet
services
menus to meet patients’ nutritional needs
➤➤ Discuss policies for dietetic services required by CMS
➤➤ Frequency of meals served
➤➤ Identify types of altered nutritional statuses
➤➤ A system for diet ordering and patient trays delivery
➤➤ Discuss what CMS surveyors will look for in dietetic and
➤➤ Accommodation of nonroutine occurrences (e.g.,
food services areas
Editor’s note: This feature explores problematic Joint Commission standards with expert advice from BOJ advisors. This
month, Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA,
parenteral nutrition (tube feeding), total parenteral
nutrition, peripheral parenteral nutrition, change
in diet orders, early/late trays, nutritional supplements, etc.)
➤➤ Integration of the food and dietetic service into the
a healthcare consultant in Trabuco Canyon, CA, and former
hospitalwide Quality Assessment and Performance
Joint Commission surveyor, discusses pending changes to Joint
Improvement and Infection Control programs
Commission standards.
➤➤ Guidelines for acceptable hygiene practices of food
service personnel
This month, let’s take a look at tracers in the dietetic
➤➤ Guidelines for kitchen sanitation
and food service areas. There have been several updates
published in recent months on the topic, so it’s a good
time to take a look at best practices.
In terms of Joint Commission standards, the following
chapters have the most bearing on dietetic services:
➤➤ Emergency Management
➤➤ Environment of Care
➤➤ Human Resources
➤➤ Infection Control
➤➤ Patient Care, Treatment, and Services
➤➤ Record of Care, Treatment, and Services
All of these policies apply whether the food services are provided by the hospital alone or through a contracted vendor.
Who is in charge here?
CMS requires that a hospital have a director of food
and dietetic services.
Surveyors will look for the following qualifications
from the director:
➤➤ Status as a full-time employee
Specific elements of performance to look at include
PC.02.02.03, HR.01.04.01, and HR.01.05.03.
Now let’s take a look at CMS’ Conditions of Participation
(CoP). The CoPs require that a hospital have organized
dietary services directed and staffed by adequate person-
➤➤ Job description—this must verify that the role is position-specific and that responsibility and authority for
the direction of the food and dietary service has been
clearly delineated
➤➤ The necessary education, experience, and training
nel. (Note: If your facility has a contract with an outside
to manage the service, appropriate to the scope and
food management company, keep Joint Commission
complexity of food service operations
leadership standards in mind as well.)
© 2009 HCPro, Inc.
> continued on p. 12
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Briefings on The Joint Commission
Page 12
Food service standards
October 2009
< continued from p. 11
CMS also requires supervision by a qualified dietitian
CMS also requires its surveyors to ensure that nutri-
who will approve patient menus and nutritional supple-
tional needs are being met in accordance with recog-
ments, provide dietary counseling, perform nutritional
nized dietary practices. Surveyors will:
assessments and evaluate patients’ tolerances for diets,
➤➤ Ask the hospital which national standard it follows
help plan and implement care to meet the nutritional
➤➤ Examine patient records to verify that diet orders are
needs of patients, and maintain pertinent patient data
to meet patients’ nutritional needs.
provided as prescribed
➤➤ From the sample patient records, identify patients
When examining the qualifications for the dietitian,
with special nutritional needs to determine whether
surveyors will look at his or her personnel file to deter-
their nutritional needs have been met; whether ap-
mine education, experience, and specialized training, as
propriate therapeutic diets have been ordered; and, as
well as licensure. They will also examine whether a non-
needed, whether their dietary intake and nutritional
full-time dietitian has sufficient hours to cover patient
status is being monitored
needs and what sort of coverage is available when the
dietitian is not available.
Dietetic manual
Finally, let’s take a look at what CMS requires for the
Menus
hospital’s therapeutic diet manual. This manual must be
Surveys of dietetic services go beyond hospital kitchen and food service to also look at those patients who
available to all medical, nursing, and food service personnel and must be approved by the facility’s dietitian.
are in an altered nutritional status, including tube feed-
The manual cannot be more than five years old, ac-
ing, total parenteral nutrition, and peripheral parenteral
cording to the CoPs. It must also receive approval from
nutrition.
the medical staff.
Once a patient is flagged as needing altered nutrition-
Prior to your next survey, ask whether your hospital’s
al status, a nutritional assessment must be performed to
therapeutic diet manual:
make sure those needs are met.
➤➤ Has been approved by the medical staff
Other types of altered nutritional status include:
➤➤ Eating disorders
➤➤ Electrolyte imbalances
➤➤ Has been approved by a qualified dietitian
➤➤ Is available to all physicians, nursing, and food service
personnel
➤➤ Follows current national standards (e.g., the current
➤➤ Diabetes
➤➤ Renal diseases
Recommended Dietary Allowances or Dietary Refer-
➤➤ Congestive heart failure
ence Intake from the Food and Nutrition Board of the
National Research Council)
CMS is very specific about who prescribes therapeutic diets and how they are documented. Although
➤➤ Addresses all types of therapeutic diets regularly ordered in the facility
a dietitian may assess a patient’s nutritional needs and
provide recommendations, the actual diet must be pre-
And don’t forget—make sure staff members actually
scribed by the practitioner who is ultimately respon-
use the manual. The old mantra of following your own
sible for the patient’s condition. This prescription must
policies applies here. Staff members must consistently use
be documented in the medical record and evaluated for
the manual for guidance when ordering and preparing
adequacy.
patient diets. n
© 2009 HCPro, Inc.
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.