On-Site Initial inspection – San Diego, CA
Another marathon. TJC surveyors are now big on asking open-ended questions. Of course, staff (nurses, techs and administrative types) are freaked out and respond as if they are being accused of abusing kittens. Then, the o-so-friendly surveyor says “I’m not trying to catch you doing something wrong”. Whatever. They have told me that they will seek out the newest, least experienced tech or nurse and ask them about emergency policies (evacuation, fire, etc) to see if they have been oriented. If they answer “I don’t know”, you are sunk. If they answer, “Let me ask my supervisor” that flies just fine. So they say. So, the surveyor said we needed to comply with some standards that aren’t in the manual anymore!! They have been removed from the ambulatory manual. Again, you must READ, READ, READ. Have the manual handy in paper AND electronic form. That way, the inspector can search for the standard and you can use the electronic SEARCH option to find faster. You don’t need to challenge but ask where the standard is they are referring to if they bring up something that sounds strange. Know that PI (Performance Improvement) is the new term – not QI. And certainly not QA. PI can be bars and graphs but this surveyor went into obtaining the mean and then giving scenarios for one, two and three standard deviations. Nooooooooooo, I’m back in school. Ain’t nobody got time for that. The usual thing like knowing what ASA level patients you will see and what age range. And then have ET tubes and paddles available for that age and weight range. Document that you KNOW where your bio-waste went. Don’t trust the tracking slip – go to the website and enter the tracking number and trust THAT. Couldn’t the company falsify the website, too? List your expiry date for your batteries in your crash cart and anesthesia cart.