- Created on Tuesday, 02 April 2002 12:53
- Written by Ken Tyler
Editors note: In our March 2002 issue we looked at the Who, What, When, Where and Why of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO.) This month Ken Tyler will share with us how to prepare for a JCAHO survey.
While much time is spent preparing for JCAHO surveys, the impact and importance is directed at patient care and documentation that supports that activity. If there was ever a true definition of direct and indirect patient care, a review of JCAHO survey protocols and processes would easily layout the definitions.Activities such as housekeeping, laundry activities, grounds management, and other support functions are considered solely indirect patient care. Although many would argue this impropriety, those are the facts.
Certainly survey managers with the JCAHO pay much attention to the aesthetic environment such as the interior design of the facility and the cleanliness and sanitary condition of a healthcare facility. This is simply because it becomes part of the environment the survey manager directly views. Laundry facilities, in house or contract can go overlooked - but you may get a walk through especially if the survey team receives advance word that laundry programs do not meet expectations for delivery and quality. If a walkthrough of your laundry is conducted, you should have in-house documentation available that address both quality and delivery.
If the survey manager is made aware of problems with the laundry, it will then receive more focus, especially in the area of safety, and documentation of training initiated with all employees. The Environment of Care Standards that are used to review laundry programs don't really address specifics related to laundry programs. The JCAHO has virtually relied on the survey technician to address concerns that are not specifically mentioned in the standards.
So what can you expect? Just about anything. Using the Boy Scout motto of "be prepared" is critical. Mock surveys usually will address more specifics in the arena of activities that may be considered indirect patient care.
I am aware of very few instances where the laundry activity has had any direct or any indirect significance related to the score given by the JCAHO. This is not to say the JCAHO does not recognize the importance of laundry programs, it does. However, the generic criteria does not permit the survey technician from specifically evaluating the program as a stand-alone function.
Regardless, laundry managers should continue to provide the quality of services that most provide. The lack of survey instruments or standards should not deter the laundry from meeting specific goals. If your facility has goals in place, then as a preparation for the JCAHO survey process, the laundry facility management should make sure these goals are met and that documentation is available to support this facet of the program. On the other hand if your laundry has specific regulations in which to follow, like conduct of wash testing, maintaining performance expectations, maintaining certain FTE levels etc., then the JCAHO surveyor may consider these requirements internal and expect that the facility has documentation to support the program. This is especially true with government facilities as directives and regulations become the rule of the day and the JCAHO may attempt to validate that you are meeting these requirements especially if it become apparent from the clinical managers that your facility may not be living up to expectations.
Once again it becomes apparent that laundry facilities will either survive or not survive based on the managers ability to assure the following:
- Employees understand safety requirements specifically Bloodborne Pathogen requirements.
- Safety plans are in affect to insure that patients will always receive quality laundry service.
- Documentation is routinely updated that reflects training conducted
- Employees understand and can explain the requirements of the facility.
- Plans in process address the future, equipment replacement etc.
- A contingency plan insures your customers will always receive the linen/textiles they require.
- Your laundry facility is clean from top to bottom!! This includes both production and non-production areas.
- Everything possible is being done to insure that the facility is safe.
- It can be demonstrated that the facility meets any external requirements that are required by any other internal or external authority.
- The surveyor can be provided with a tour of the facility and can explain every facet of the operation.
- As the laundry plant manager you have the qualifying credentials. While no requirements exist, credentials are important.
- If laundry equipment was purchased, it was inspected to insure it was safe, that it would meet your requirements and that your employees were trained.
- The ability to demonstrate/document that you are meeting some quality requirements/expectations and that you discuss these issues with your customers.
Quick Rinse - News From Around The World
Dirty Laundry Dumped In Northern California
MARYSVILLE, Calif. — Dirty laundry dumped on a highway in northern California stopped traffic and closed the roadway. The laundry, from an area medical center, was dumped when the driver of the big-rig transporting the laundry fell asleep at the wheel. The trailer jackknifed when the driver realized he’d drifted onto the shoulder and he tried to steer back onto the highway