Volume 2, Number 4; July 2008 ... nursing practice, quality of care and patient
safety. Please note the following excerpt from Medical Staff President Michael ...
Editor: J. Cappon, MD
Volume 2, Number 4; July 2008
Magnet The American Nurses Credentialing Center (ANCC) has designated CHOC as a Magnet Facility. This is the highest honor bestowed to a hospital for nursing excellence. CHOC now joins an elite group of hospitals nationwide – including only 24 children’s hospitals in the country – that has earned this distinction. With Magnet distinction, the ANCC recognizes CHOC’s tireless commitment to the highest standards of nursing practice, quality of care and patient safety. Please note the following excerpt from Medical Staff President Michael Muhonen’s letter of congratulation to the CHOC Nursing Staff: “…The Medical Staff of Children’s Hospital of Orange County wishes to extend our proudest and most sincere congratulations to CHOC’s Nursing Staff upon the recently announced award of Magnet status. We are keenly aware Magnet accreditation is an esteemed honor and reflects what we as CHOC physicians have known all along: • • •
CHOC’s nurses are among the nation’s finest; CHOC’s nursing care at the bedside and their commitment to the highest standards and quality of care delivery brings our best medical care to fruition; CHOC nurses play a vital role as colleagues in medical staff committees and other interdisciplinary teams dedicated to improving patient safety and quality of care.
We take pride in your well-deserved accomplishment and are confident that Magnet status will help solidify CHOC’s already strong reputation as a center of nursing excellence, aid in recruitment/retention, and deepen individual professional satisfaction as an integral part of a nationally recognized children’s hospital. CHOC is an incredible place to be a physician and we thank you collectively for providing the nursing care that makes it so…” Commenting on the commitment demonstrated across all of the CHOC disciplines, one of the Magnet appraisers said, “The synergy here is palpable.”
Joint Commission Survey Preparation An unannounced triennial accreditation Joint Commission (and possibly others) Survey is anticipated in the very near future. Historically, CHOC is visited soon after St. Joseph Hospital, which had a successful Survey in mid-July. The basic mechanism of the survey process continues to be Tracer Methodology, in which, for example, a patient may have any or all of his/her relevant aspects of care throughout the institution (“traces”) evaluated; for instance, surgery, medication management, infection control, or information transfer. All physicians and associates are potential contacts for the Survey team. There are many things the medical staff can do to help make the survey accurately represent the CHOC way of patient care, and hence successful, among them: 1. Ensure that appropriate medical records (eg, H&Ps, Operative Notes, Discharge Summaries) are generated and/or authenticated in timely fashion. 2. Authenticate verbal and telephone orders promptly, and always within 48 hours. 3. Avoid the use of Do Not Use Abbreviations (see list below) in all patient care documentation (CPOE has eliminated this from medication ordering, but Progress Notes, free-texting within CUBS, etc., can still be problematic). a. U, u (unit) b. IU (international unit) c. QD, Q.D., qd, q.d. (once daily) d. QOD, Q.O.D., qod, q.o.d. (every other day) e. Trailing zero (X.0) (potential ten-fold error) f. Lack of a leading zero ( .X) (potential ten-fold error) g. MS, MSO4, MgSO4 (write substance name) 4. Ensure that Attending Physician oversight of Residents and overall management of patients is reflected in the medical record. 5. Apply the same thoroughness of the surgical Universal Protocol and TimeOuts to procedures performed elsewhere on campus (SJH came under great scrutiny in this regard). Please refer to the excellent “Notes for Continued Survey Readiness” link, authored by Catherine Wassenberg RN, MA, MBA, on the PAWS home page for more detailed information on these and other aspects of survey preparation. In addition, a list of potential Institute for Medical Quality (IMQ) queries regarding functions and responsibilities of the medical staff was re-distributed by email to all members by Dr. Minon last week. Please contact the Medical Staff Office (x8407) should questions exist. Bottom Line: Continue to do what the collective Medical Staff does hundreds, if not thousands of times, safely and effectively, each day. Surgeon-In-Chief Ali Kavianian, MD, has been appointed to the newly created position of CHOC Surgeon-in-Chief, effective July 2008. A Pediatric General Surgeon with 25 years of successful practice at CHOC, Dr. Kavianian will provide leadership for all pediatric surgical services, and serve as a liaison between Administration and the Surgical Medical Staff. The Surgeon-In-Chief (SIC) will promote CHOC surgical services and ensure the ongoing advancement of quality and patient safety practices. Additionally, the SIC will be an active participant in critical medical staff functions including the Master Campus Plan, the CHOC Strategic Plan, and the MEC.
