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MEDLIB-L  October 1996, Week 1

MEDLIB-L October 1996, Week 1

Subject:

Report on the JCAHO visit (long)

From:

Webster Library <[log in to unmask]>

Reply-To:

Medical Libraries Discussion List <[log in to unmask]>

Date:

Tue, 1 Oct 1996 15:11:00 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (147 lines)

The JCAHO visited the Corporation the week of September 23.  Since two
hospitals are being surveyed, it was spread over 6 working days.  The
main resuslts were reported on Friday afternoon, but were not final,
as a separate Mental Health survey took place yesterday.
The final score will be verified at JCAHO headquarters a few days later.
Overall, spirits are high, since the Friday score was 97 !   Out of
the 488 specific standards, 482 were in compliance, with the
remaining six "in substential compliance" (minor problems: 1. "potentail"
infectious medical waste handling in patient room - something to do with
garbage cans with and without lids, and red bags - a committee is being
asigned to look into it and select appropriate garbage cans, etc. which I
will mention later. 2. Some small Medical Staff Credintialling issue.
3.SOmehting to d owith thermometers. 4. Too many people/chairs in
hallway. 5. Organ donation review  schedule.).
 
Hospital reeived 94 with commendation 3 years ago, and Administration
here is hoping for at least same. It was hard work, everybody was
nervous, overworked and tension was almost palpable.  Yesterday, the QI
office received the  new 1997 Standards...
 
The surveyors were: William St. Clair, MD
                    Barbara Maher RN  (I think she was athe groups leader)
                    John Henderson (Adm)
                    Leonard Brink, ACSW (for Chemical Depedency)
                    Paul Hargis, FACHE (Adm) (for Ambulatory Serv.)
 
I was able to locate a number of hospitals where these persons visited
earlier, and several of our Dept. Heads made contacts.
 
What went on?
In ANesthesia, surveyor asked to be taken a Post Anesth. awake patient,
and proceeded to ask a lot of detailed questions about pre-procedure
education, options, pain, etc.  (Similar approach - direct contact with
patients, occured again on several floors).
 
NURSING:  I have scant information, except that "she is tough - but it is
going well" from my VP who is also VP nursing and accompanied the surveyor.
 
In Pathology, a comment was made regarding adviseability of _not_ storring
caustic chemicals in overhead bins.
 
Housekeeping : two incidents:1. an employee was asked how oftern he/she
changes the water in the bucket (on patient floor).  "When dirty" did not
suffice - wanted to know what the policy says. 2. Employee was asked what
to do in case of fire, and did not kno the answer ("RACE" - and we were
all given "cheat cards" to attach to our name badges).
 
Pt. Registration: Question: How is  confidentaiality maintained at
registration time (since counters are open) - accepted answer:
registering one patient at one time.
 
Patient Education:  I did not attend this meeting (High Holidays day off).
As a member of the Committee, I sent my Assistant,
Linda, who worked with the nurses and was resonsible for the patient
Education Database data entry.  THe Committee is multidisciplinary.
Surveyor inquired as to where and how nurses "learn how to teach" and how
the actual patient learning (effectiveness) is assessed/measured.  He
also asked about how we determine what the community wants/needs, and
seemed to be satisfied with the answer from PR re various surveys and
esp. the developments of the Mammography clinic at a area shopping mall.
Linda had an opportunity to note the availabilty of books on "how to
teadh/patient education on the hospital wide network catalog, and the
development of the specific PAT (PAtient Teaching) catalog one
same (which was pushed through by the Library and completed in
time for this survey, and culls a lot of high phraise in house).  The
report the I received from the Committee Chair is that he was
"most impressed".
 
Information Systems:  An overview was presented by IS administrator,
explaining the overall hospital plan, and the specifics of is being
done.  Even though we are part of this overall "integrated" plan, I (and
the Medical Records Administraotr) learned A LOT, since we have never
seen or heard such a presentation before.  It is not freely shared.
He was followed by a physician, Chair of the
Corporate Information Systems Advisory COmmittee (advisory to
the CEO and the Board).  As with the Pt. Education visit, the surveyor
was most impressed and did not ask any "tough" questions.  At some point
he explained that 45% of his role is to teach, and the other is to see
that the hospital is on track and has a plan to follow through.  In the
discussiion that followed, the Library was noted and database networking
was mentioned.  I had an opportunity to note how perceived need brought
about the development of the PAT database, but that was about all.
(Same surveyor was in the Library earlier in week - see report below).
 
Library visit:  I was expecting the surveyor, as I found out almost last
minute where he visited the previous week.  Since I was instructed to
deliver the Library Policy Manual to a centralized location, I hurriedly
set up a second copy.  Aparently he was specific in noting that he want
to visit the Library as part of the "builging tour", and two separate calls
from Administratin gave us the "official:.    When he walked into the
Library, he inquired as to the "boss" person, and I introduced myself
(hand shake, too), and asked if he would like a tour, or if he has
anything specific in mind, and he responded that he would like to go into
my office - "you so have an office?"  The surveyor and the jurnior Adm
(not a library user) came into my office (not much room for more).  His
eye lighted on my lap-top, and he asked my how I liked it, and we
discussed cursors (my is "nervous" and drives me nuts), and I noted that
I prefer to work on the larger terminals in the Library proper.  He then
remembered why he was there for and asked me if I have a Policy Manual,
and if he can see it, and I excused myself and went out to get if off the
shelf in the main Library office.  His second question (also anticipated)
was "do you have a budget and is it in the Manual", to which I responded
that indeed we do, but that the Manual just noted it (pointed to the Table
of COntents - this was a last minute addition...).  He proceeded to aks
me questions that no JCAHO surveyor has ever asked me before (this is
probably my 6th - if not 7th round with JCAHO).  He asked for totla budget,
percentage of operataing $$ to salary, number of staff, mix (professional
vs. technical, and is it enough, my credentials and where I got the
MLS from, and how much financila support we get from the Medical
Staff ("none").  He then wanted to know if someone want to gift us
money, do we turn it away, and it gavae me the opportunigy to tell
him about the special gift fund and the grant monies.  At some point
I had the chance to give him a "gift package" - Library brochure,
Annual report, some book lists and handouts (he wnated to know who
gets the Annual Report).  He volunteered to "share" the handout with
the rest of the Committee that evening, and I assured him that I
have plenty copies and that he does not havae to retunr whatever.
His last question while in my office was if I "teach Library Sciene"
- and I should have asked him why he asked such a question, instead
of looking a bit puzzled and saying "no".
 
I offered a tour, and highlighted the networked database stataions, and
demonstrataed the PAT online catalog (I already knew that he heard about
it), and ended with the "highlight" - the view of the Bahaii and the lake
, perfect;y framed in one of the windows, and the colors that day were
spectacular.  (I call it the Million dollar view).
 
If any of your administartors want to chat with any of ours, give me a
call land I will refer you.  Another member of Medlib-L "inherited" my
locator list, which was extremely useful, and I hope she will be able to
help you identify the surveyors.   If not - I recommend that you start
keeping a file of just plain copies of the floated names of surveyors,
and scan them for "matches" prior to the JCAHO visit.  The more of us who
list the names, the better servicef we can provide to our institution
(start collecting at least a year prior to the intended vist - there
seemed to have been a hiatus this past summer, with activity very heavy
just now.
 
I am not going to spend time Proof reading - so excuse the off key
strokes (it is NOT typos!).
 
                               Dalia Kleinmuntz
                               Webster Library, Evanston Hospital
                               [log in to unmask]     (847) 570-2665
                                                        (847) 570-2926 FAX
** Behold the turtle who makes progress only when he sticks his neck out **

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April 2006, Week 4
April 2006, Week 3
April 2006, Week 2
April 2006, Week 1
March 2006, Week 5
March 2006, Week 4
March 2006, Week 3
March 2006, Week 2
March 2006, Week 1
February 2006, Week 4
February 2006, Week 3
February 2006, Week 2
February 2006, Week 1
January 2006, Week 5
January 2006, Week 4
January 2006, Week 3
January 2006, Week 2
January 2006, Week 1
December 2005, Week 5
December 2005, Week 4
December 2005, Week 3
December 2005, Week 2
December 2005, Week 1
November 2005, Week 5
November 2005, Week 4
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November 2005, Week 2
November 2005, Week 1
October 2005, Week 5
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April 2005, Week 5
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April 2005, Week 3
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April 2005, Week 1
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March 2005, Week 4
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February 2005, Week 1
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January 2005, Week 3
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January 2005, Week 1
December 2004, Week 5
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December 2004, Week 3
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December 2004, Week 1
November 2004, Week 5
November 2004, Week 4
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November 2004, Week 1
October 2004, Week 5
October 2004, Week 4
October 2004, Week 3
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October 2004, Week 1
September 2004, Week 5
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September 2004, Week 2
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June 2004, Week 5
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April 2004, Week 5
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April 2004, Week 3
April 2004, Week 2
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March 2004, Week 5
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February 2004, Week 5
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February 2004, Week 2
February 2004, Week 1
January 2004, Week 5
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January 2004, Week 3
January 2004, Week 2
January 2004, Week 1
December 2003, Week 5
December 2003, Week 4
December 2003, Week 3
December 2003, Week 2
December 2003, Week 1
November 2003, Week 5
November 2003, Week 4
November 2003, Week 3
November 2003, Week 2
November 2003, Week 1
October 2003, Week 5
October 2003, Week 4
October 2003, Week 3
October 2003, Week 2
October 2003, Week 1
September 2003, Week 5
September 2003, Week 4
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September 2003, Week 2
September 2003, Week 1
August 2003, Week 5
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July 2003, Week 2
July 2003, Week 1
June 2003, Week 5
June 2003, Week 4
June 2003, Week 3
June 2003, Week 2
June 2003, Week 1
May 2003, Week 5
May 2003, Week 4
May 2003, Week 3
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April 2003, Week 5
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April 2003, Week 3
April 2003, Week 2
April 2003, Week 1
March 2003, Week 5
March 2003, Week 4
March 2003, Week 3
March 2003, Week 2
March 2003, Week 1
February 2003, Week 4
February 2003, Week 3
February 2003, Week 2
February 2003, Week 1
January 2003, Week 5
January 2003, Week 4
January 2003, Week 3
January 2003, Week 2
January 2003, Week 1
December 2002, Week 5
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December 2002, Week 3
December 2002, Week 2
December 2002, Week 1
November 2002, Week 5
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November 2002, Week 3
November 2002, Week 2
November 2002, Week 1
October 2002, Week 5
October 2002, Week 4
October 2002, Week 3
October 2002, Week 2
October 2002, Week 1
September 2002, Week 5
September 2002, Week 4
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September 2002, Week 2
September 2002, Week 1
August 2002, Week 5
August 2002, Week 4
August 2002, Week 3
August 2002, Week 2
August 2002, Week 1
July 2002, Week 5
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July 2002, Week 3
July 2002, Week 2
July 2002, Week 1
June 2002, Week 5
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June 2002, Week 2
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April 2002, Week 5
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April 2002, Week 1
March 2002, Week 5
March 2002, Week 4
March 2002, Week 3
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February 2002, Week 1
January 2002, Week 5
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January 2002, Week 3
January 2002, Week 2
January 2002, Week 1
December 2001, Week 5
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December 2001, Week 3
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December 2001, Week 1
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October 2001, Week 5
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October 2001, Week 3
October 2001, Week 2
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August 2001, Week 5
August 2001, Week 4
August 2001, Week 3
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July 2001, Week 1
June 2001, Week 5
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June 2001, Week 1
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May 2001, Week 3
May 2001, Week 2
May 2001, Week 1
April 2001, Week 5
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April 2001, Week 3
April 2001, Week 2
April 2001, Week 1
March 2001, Week 5
March 2001, Week 4
March 2001, Week 3
March 2001, Week 2
March 2001, Week 1
February 2001, Week 4
February 2001, Week 3
February 2001, Week 2
February 2001, Week 1
January 2001, Week 5
January 2001, Week 4
January 2001, Week 3
January 2001, Week 2
January 2001, Week 1
December 2000, Week 5
December 2000, Week 4
December 2000, Week 3
December 2000, Week 2
December 2000, Week 1
November 2000, Week 5
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November 2000, Week 2
November 2000, Week 1
October 2000, Week 5
October 2000, Week 4
October 2000, Week 3
October 2000, Week 2
October 2000, Week 1
September 2000, Week 5
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September 2000, Week 1
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May 2000, Week 1
April 2000, Week 5
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April 2000, Week 1
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March 2000, Week 3
March 2000, Week 2
March 2000, Week 1
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February 2000, Week 4
February 2000, Week 3
February 2000, Week 2
February 2000, Week 1
January 2000, Week 5
January 2000, Week 4
January 2000, Week 3
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January 2000, Week 1
December 1999, Week 5
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December 1999, Week 1
November 1999, Week 5
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April 1999, Week 1
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February 1999, Week 4
February 1999, Week 3
February 1999, Week 2
February 1999, Week 1
January 1999, Week 5
January 1999, Week 4
January 1999, Week 3
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January 1999, Week 1
December 1998, Week 5
December 1998, Week 4
December 1998, Week 3
December 1998, Week 2
December 1998, Week 1
November 1998, Week 5
November 1998, Week 4
November 1998, Week 3
November 1998, Week 2
November 1998, Week 1
October 1998, Week 5
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April 1998, Week 1
March 1998, Week 5
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March 1998, Week 3
March 1998, Week 2
March 1998, Week 1
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February 1998, Week 2
February 1998, Week 1
January 1998, Week 5
January 1998, Week 4
January 1998, Week 3
January 1998, Week 2
January 1998, Week 1
December 1997, Week 5
December 1997, Week 4
December 1997, Week 3
December 1997, Week 2
December 1997, Week 1
November 1997, Week 5
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November 1997, Week 3
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October 1997, Week 3
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October 1997, Week 1
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September 1997, Week 2
September 1997, Week 1
August 1997, Week 5
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April 1997, Week 5
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March 1997, Week 5
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February 1997, Week 1
January 1997, Week 5
January 1997, Week 4
January 1997, Week 3
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January 1997, Week 1
December 1996, Week 5
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December 1996, Week 3
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December 1996, Week 1
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October 1996, Week 3
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June 1996, Week 5
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June 1996, Week 3
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May 1996, Week 4
May 1996, Week 3
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May 1996, Week 1
April 1996, Week 5
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April 1996, Week 1
March 1996, Week 5
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March 1996, Week 3
March 1996, Week 2
March 1996, Week 1
February 1996, Week 5
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February 1996, Week 1
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January 1996, Week 4
January 1996, Week 3
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January 1996, Week 1
December 1995, Week 5
December 1995, Week 4
December 1995, Week 3
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December 1995, Week 1
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December 1994, Week 5
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