Hot button accreditation issues

A significant minority of standards account for a significant majority of adverse findings during any accreditation survey. The following is a list of common “hot button” issues for standards directly or substan­tively attributable to the medical staff:

• Pre- and postprocedure documentation: Surveyors have focused extensively on pre- and postprocedure medical record documentation. This applies not only to the perioperative area but to any place a procedure using moderate sedation or anesthesia is performed. This includes the emergency department, bedside procedures in critical care, the endoscopy suite, the cardiac catherization lab, interventional radiology, and the bronchoscopy suite. Specif­ically, surveyors are looking for an H&P that meets the required standards, the presence of an immediate preprocedure note documenting ASA class and any change (or note that there has been no change) since the H&P was dictated, and an immediate postprocedure note that addresses the following six required elements:
  • Procedure performed
  • Description of the procedure
  • Findings
  • Estimated blood loss
  • Specimens removed
  • Postoperative diagnosis

Further, there must be a dictated note completed within 24 hours.

• Informed consent: There has always been an emphasis on informed consent; however, again it applies to all hospital areas and not just the operating room. Surveyors seek evidence of consents for anesthesia, blood transfusions, and central line insertions in the critical care unit, to name a few.
• Restraint documentation: A perennial focus is that restraint documentation must follow standards and hospital policy. Medical staff leaders need to know these standards and that they are followed and documented.
• H&P: There are a plethora of findings regarding H&Ps, including a completed and document­ed H&P must be in the medical record no more than 30 days prior to or 24 hours after hospi­tal admission or registration. Most definitely, an H&P is required prior to surgery or a proce­dure involving moderate sedation or anesthesia regardless of whether care is provided in an outpatient or inpatient basis. The medical staff bylaws must state which practitioners have privileges within scope of license to perform an H&P and whether there are any limitations on the extent of the H&P (e.g., podiatrists, dentists). H&P is limited in the case of certain practitioners (e.g., a podiatrist may conduct that portion of the H&P pertinent to his or her specialty and the remainder of the H&P shall be documented by a practitioner. Additionally, content of the H&P should be specified by the medical staff in its bylaws and documents.