AMBULATORY SURGERY

Meeting National Standards:Taking a Deep Breath?

Nancy Burden, MS, RN, CPAN, CAPA

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STAFF MEMBERS should feel happy andproud of the work done preparing for andgoing through an accreditation or other survey.Hurrah for everyone when a successful surveyis completed! Afterward do you take a deepbreath? You bet. But don’t rest too long. It issoon time to “future-think.” How do we sustainthe incredible level of detail that we all madehappen? How do we continue to focus on therequirements of our accreditation or license andknow that we are “ever-ready” for a pop-in visit?

The first step is to ensure that everyone focuseson the right thing. That “thing” is not “beingready for a survey”—it is doing what is right forour patients, day in and day out. Does it soundsilly that we cannot put anything under the sinkexcept cleaning solutions? Does that sound likeoverkill to make our lives crazy? Think about itthis way. Would you open a candy bar and putit, unwrapped, under your bathroom or kitchensink at home for a month or so, then eat it?Yuck! When we put paper towels, equipment,purses, or other things under a sink, contami-nants from water leakage, dust from the floorand our shoes, and nighttime creepy crawliesthat we don’t see all have 100% access to thatitem. Then we pick it up to use it, forget to

Nancy Burden, MS, RN, CPAN, CAPA, is Director of Ambu-latory Health Services, Morton Plant Health Services, Clear-water, FL.

Address correspondence to Nancy Burden, MS, RN, CPAN,CAPA, 10949 East Bay Drive, New Port Richey, FL 34655;email address: ncburden@tampabay.rr.com.

© 2006 by American Society of PeriAnesthesia Nurses.1089-9472/06/2101-0008$32.00/0

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ash our hands, touch patients and equipment. . Well, you get the message.

oes it sound like overkill that before everyrocedure we ask for verbalization of the pa-ient’s name and a second identifier such as datef birth and we look at the their ID bands too?ust we ask every patient to explain what they

re having done and check that against theedical record and the schedule? Well, this isot just a nice thing to do. It is imperative. It isolicy. It is our responsibility. There are notnough adjectives in the dictionary to describeow important this is. Yes, it is an accreditationequirement, but even more, it is policy; it ishat we would want for ourselves and our

amily members; it is the right thing to do.

ccreditation standards are not created lightly,ven though we may sometimes think that peo-le sit in a room somewhere in a conferenceoom giggling at the hoops they could make usump through. Actually, the process is quiteefined. Data from past surveys across the coun-ry are used along with current literature, re-earch, and—believe it or not—input from yound me to refine old and new standards.or example, on the home page for the Jointommission on Accreditation of Health Carerganizations (JCAHO, available at: http://ww.jcaho.org) right now there are multiple

ets of draft standards for 2007! JCAHO placeshe drafts out for field review—that means eachf us can have a say in how a potential newtandard will affect our patients’ care and ourork. The drafts remain in place until all field

eviews are processed and the accrediting body

urnal of PeriAnesthesia Nursing, Vol 21, No 1 (February), 2006: pp 40-42

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MEETING NATIONAL STANDARDS 41

makes a final determination about whether toimplement them into new standards and inwhat final form.

Currently, the drafts for 2007 include topicssuch as physician credentialing, how to prop-erly enact emergency drills, many new leader-ship requirements, Human Resources manage-ment during disasters, testing of our emergencymanagement plan, a requirement for new de-mographic data to be gathered on all patients,oversight of contracted services, and 2007 revi-sions to the National Patient Safety Goals. Quitea mouthful isn’t it? We don’t know what lan-guage and which changes or additions willmake it into the final 2007 standards, but youcan be sure the changes will continue to focuson doing the right thing as far as patient care isconcerned.

Our role as individual providers will continue tobe the following:

● knowing the standards that affect ourareas of care,

● applying the standards to the care weprovide 100% of the time,

● being consistent across all areas of ourfacility,

● revising internal policies to encompassnew regulations,

● maintaining information about how weare performing against the standards(Performance Improvement Plans, Envi-ronmental Surveys, etc), and finally,

● personally caring about our perfor-mance because it is the right thing to do,not because a standards book requires it.

In addition to accreditation, we have state licen-sure, national professional organizations, andMedicare/Medicaid standards to implement andmonitor. It is essential to implement an orga-nized, systematic, and comprehensive plan fordealing with not only current standards but alsonew regulations and changes in laws and stan-dards. Table 1 provides some ideas on how to

implement such a plan. i

ach day, each month, each year we must focusn many areas—the quality of care we provide,roper and timely exchange of information,afety as foremost, and the continuation of pa-ient-focused service that places every one ofur patients as the most important person inur world during each encounter. Be in-olved—care about the goals and bring your

Table 1. Implementing a Plan for Compliance

. Monitor adherence to current regulations● Develop a written compliance plan● Create indicators for monitoring compliance (ie:

# unapproved abbreviations in record, % timeselements not met in emergency drills)

● Assign responsibility for portions of regulationsto appropriate people (ie, Safety Officer whomonitors National Patient Safety Goals andcommunications, and implements changes)

. Monitor and implement changes to regulations● Ensure you have access to changes — ie, be on

e-mail lists, subscribe to publications that presentupdates, monitor web sites

● Maintain active membership in national groupssuch as nursing and other professional industryorganizations

● Purchase or secure annual updates● Monitor legislative changes that will affect care

. Create a comprehensive communication plan● Employ various communication methods: verbal,

written● Include topics at each staff meeting● Provide articles, copies of policies, etc, and ask

staff to initial or sign when read● Involve everyone — find effective team member

leaders but remember to include the quiet peopleas well and provide them with responsibilities

. Make compliance fun● Create quick puzzles and games● Create a space/room where various elements are

noncompliant — team to find errors● Recognize a monthly or weekly “Standards

Hero” caught doing something right● Enact creative emergency drills that are realistic—

ie, a “person” on the floor unconscious in lobby;unexpected telephone call about a bomb; flashfire in the OR (can purchase battery-operated“flame” to simulate)

deas forward to make your department con-

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tinue to shine! Just like all parts of a body needto work in unison for any action to occur, sotoo, does each person in an organization needto function together with others to ensure theunit functions properly as a whole. In the high-

rators, managers, nurses and other healthcareroviders, business office personnel, supportersonnel, and contracted suppliers—com-ines their efforts in a unified manner to pro-ide the best possible care that is safe, efficient,

performance organization, everyone—adminis- and effective.