If I were a JCAHO surveyor, I would conduct a hospital review of Nursing, Respiratory Therapy, and the Physicians on an unannounced basis. I would chose this method because it helps organizations provide safe, quality care that’s continuous, not sporadic in nature (DeLorenzo, 2005). As a means of pinpointing gaps in problems related to patient safety and quality and offer guidance to leadership, physicians and other members of the healthcare team, I will observe and interview the nurses, respiratory therapists, physicians, and perform patients and systems tracers (the Tracer Methodology) which puts the hospital in a position that forces them to prove that they practice what their policies and procedures require. My patient tracer will involve
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In my general survey, I will verify whether or not initial assessments by consults were conducted, e.g. physical therapy, respiratory therapy, speech-language pathology, social work; consults were initiated based on screening criteria in the datasets, e.g. smoking cessation, PFT; there were no medical interferences or diagnostic tests performed without an order by the MD; the progress notes reveal multidisciplinary development and follow-through; and, there is patient understanding of education. In my survey of the work environment and fire and patient safety, I will confirm whether or not equipment is correctly cleaned and disinfected in between patient use with the appropriate hospital-approved disinfectant, there are no expired supplies being in stock or being utilized, HIPAA regulations are being complied, oxygen tanks are safe, secure, and properly stored, and hallways are kept …show more content…
Within a couple of weeks after the survey, I will make available the hospital’s elements of performance (EPs) scores that determine if a standard is in compliance: 0 = insufficient compliance, 1 = partial compliance, and 2 = satisfactory compliance (Facts about Scoring and Accreditation Decisions, 2015, para. 2). In Facts about Scoring and Accreditation Decisions (2015, para. 3), if the hospital receives any partially compliant or insufficiently compliant EPs, they must be addressed via the Evidence of Standards Compliance (ESC) submission process within 45 or 60 days, depending on the criticality of findings and immediacy of
In my general survey, I will verify whether or not initial assessments by consults were conducted, e.g. physical therapy, respiratory therapy, speech-language pathology, social work; consults were initiated based on screening criteria in the datasets, e.g. smoking cessation, PFT; there were no medical interferences or diagnostic tests performed without an order by the MD; the progress notes reveal multidisciplinary development and follow-through; and, there is patient understanding of education. In my survey of the work environment and fire and patient safety, I will confirm whether or not equipment is correctly cleaned and disinfected in between patient use with the appropriate hospital-approved disinfectant, there are no expired supplies being in stock or being utilized, HIPAA regulations are being complied, oxygen tanks are safe, secure, and properly stored, and hallways are kept …show more content…
Within a couple of weeks after the survey, I will make available the hospital’s elements of performance (EPs) scores that determine if a standard is in compliance: 0 = insufficient compliance, 1 = partial compliance, and 2 = satisfactory compliance (Facts about Scoring and Accreditation Decisions, 2015, para. 2). In Facts about Scoring and Accreditation Decisions (2015, para. 3), if the hospital receives any partially compliant or insufficiently compliant EPs, they must be addressed via the Evidence of Standards Compliance (ESC) submission process within 45 or 60 days, depending on the criticality of findings and immediacy of