Apologies to those who are also JCAHO-Watch members.

Morehead Memorial Hospital was surveyed January 27-29, 1998.  The surveyors
were
        Wendell Schmitt - Administrator
        A. Musser, MD - Physician
        Richard Ashton, RN, JD - Nurse


The administrator toured the building.  He asked various employees where
the MSDS sheets were. Asked an ER nurse where samples were kept.  Called
the switchboard from an elevator telephone. Looked in ceilings at
firewalls.  He did not visit the library.

Managers meeting questions - Administrator
What input do you have in the budget process?
What input do you have in development of policies?
How are you and your staff educated?
How were you taught the quality improvement process?
Does the hospital have a code of ethics?  What does it say?
Who is involved in quality management?
What input do you have in the environment of care?
What do you do to encourage employee retention?
The adminsitrator looked at me and said, "I don't mean to put you on the
spot but I would like for your colleagues to answer this.  How are your
knowledge-based information needs met?" I sat back and listened to several
people talk about how well and quickly they got answers to their questions
from a variety of sources.  One even mentioned how we use this listserv to
see what is done in other institutions.  Then Mr. Schmitt made the comment
that the standards don't require a library with books and journals, it just
requires that the information needs be met.  I jumped in and said that we
did have a library and that I appreciated the hospital giving me a budget
sufficient to keep the print information up-to-date.  Several other
managers then commented on how often they see students and staff in the
library reading the books and that they also were glad the print
information was there.

Information Management questions - Administrator
How was the IM plan formulated?  (So far as I know, he never read the plan.)
After we talked about the needs assessment, he asked what was done with the
information gained from the assessment.
What is your disaster recovery plan?
What about confidentiality and security of the computer system?
How do you ensure the completeness and security of the medical record
including hospital owned physican offices?
How do you perform your medical record review?
How long do you keep medical records?
How soon is the doctor's dictation transcribed?
Do you allow signature stamps?  What is your policy?
Can I obtain a copy of my medical record?
How do you access the medical record after hours?
How do you evaluate your information management process for improvement?
What is the selection process for knowledge-based information?
How is knowledge-based information accessed after hours?

~~
Cheryl Williams, Hospital Librarian
Morehead Memorial Hospital
117 E Kings Hwy
Eden, NC 27288
336-623-9711 x2266; 336-623-6182 FAX; [log in to unmask]
http://www.morehead.org

All opinions expressed are my own and may not necessarily be those of this
hospital.