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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 6

Susan Wisniewski


By Susan Wisniewski, CPHQ - Manager, Accreditation and Regulatory Compliance

The California Department of Public Health
Initiates Patient Safety Surveys

The California Department of Public Health (CDPH) will implement a Patient Safety Licensing Survey process November 1, 2010.  The purpose of the survey is to assess hospital compliance to laws passed since 2006 (11 patient safety statutes). Pilot surveys will be conducted August 27 through October 31, 2010, three in each district; our district includes Mariposa, Merced, Madera, Fresno, Kings and Tulare Counties. Because we are the only pediatric hospital in the district, a pilot survey seems likely. Regular surveys will begin November 1, 2010, and will be conducted at each hospital every three years. The survey team is usually comprised of two nurse evaluators who will be here for approximately two days. 

There will be an emphasis on patient safety statutes in the following areas:

  • End of Life Care
  • Brain Death
  • Hospital Services (new or discontinued services; relocation of services)
  • Patient Safety and Infection Control
  • Discharge Planning
  • Dietary
  • Immunizations
  • Fair Pricing/Debt Collection (financial assistance and charity care).

Patient Safety and Infection Control will be a major component of the survey.

Surveyors will focus on methicillin-resistant staphylococcus aureus (MRSA), cleaning/disinfection, the patient safety plan, central line insertion procedures and hand hygiene. They will also review areas that need to be reported annually, such as central line associated bloodstream infections (CLABSI), surgical site infections, ventilator associated pneumonia and the judicious use of antibiotics. Of importance is your knowledge of and your ability to articulate Children’s policies and practice for each topic.

Surveyors will conduct chart reviews – both open and closed charts, review policies and interview staff.  They will review:

  • Policies and compliance to policies
  • Education and training related to policies and documentation of education and training
    (by reviewing staff and physician personnel files)
  • Tracking and monitoring records to ensure continued compliance
  • Reporting requirements within the hospital or to outside entities (as required)
  • Whether staff can speak to the process detailed in the policy

To help get us ready for the survey, the Accreditation and Regulatory Department staff has developed a tool for a self assessment to determine our level of compliance in these areas. Section Leads and Executive Champions have been identified and provided with resources to conduct a self assessment in their identified area. The results will be used to develop a Gap Analysis Report and work will begin immediately on action plans as needed.  (For instance, a policy may need to be updated or education provided) 

The self assessment must answer the following questions about each policy:

  • Are all components listed in the law and supportive documents present in the policy?
  • Has training/education been completed? Is there documentation of who has been trained educated?
    Where is the information kept?
  • Is policy compliance being tracked or monitored? How is data collected?
  • Is a report to a committee, leadership or another entity required?
  • Can staff speak to the process?

What can you do?  If you don’t know or understand how these areas relate to you, talk with your supervisor; become familiar with the policies and think about how you would answer questions about the topic. For instance, if a surveyor is on your unit surveying infection control practices, MRSA in particular, and asks you about information you provide at discharge for a patient who has tested positive for MRSA, how would you answer the question? Do you know where the policy is located?  Do you know what Children’s practice is? All resources are posted on the Complete Quality Web page on the George Page. Just like other surveyors, the reviewers want to talk with you and see how you take care of the kids.  You are the expert on your role and your patient’s care.

Remember keeping children safe = ready for survey! 

In This Issue

Great Moments

Shining Stars

Pediatric Early Warning Tools

Patient Safety Survey

Informatics: The Language of Nursing

Nursing Peer Review

NICU Outreach Education

What is “Just Culture”?

Patient Satisfaction Comments