Automated Documentation Makes JCAHO Preparation Easy

Like many other medical facilities, the University of Miami Hospital and Clinics undergoes periodic review by JCAHO -- a review that, for our GI department, can include scrutiny of everything from infection control, safety and risk-management procedures to patient relations policies and procedures. If we've done well, JCAHO comes back every three years; if we haven't, they return in just two years.

Until recently, preparing for this process was definitely exhausting -- especially for a facility handling our volume of colonoscopies, endoscopy and therapeutic procedures. Perhaps that's why JCAHO itself has always recommended that we begin preparing for our review six months to a year ahead of time.

Indeed, we have traditionally spent many weeks gathering forms and patient documentation for this review. It has easily involved at least two weeks of intensive preparation, with a solid week devoted to completing the necessary paperwork.

Automating Our Processes

After our previous JCAHO review in June 1999, our department made a major change that reduced our 2002 preparation time to a matter of hours: the installation of ProVation RN procedure-documentation software in both our GI and colorectal divisions.

Developed by ProVation Medical, Inc., the software is an easy-to-use package that automates the procedure-documentation process for our nurses. It collects data automatically from interfaced vitals monitors. Where it does require us to enter information, it allows us to do so simply by clicking through a series of menus that follow our normal workflow. For facilities like ours, capabilities such as these mean improved productivity, reduced paperwork and better patient care. We can retrieve the data and look at it from many different perspectives to tailor our activities appropriately.

Meeting Exceptionally Stringent Requirements

Because our department is managed by the OR at the University of Miami Hospital and Clinics, we have exceptionally stringent documentation requirements -- beyond what you'd find in most other GI units. Fortunately, our software has allowed us to capture all the additional information we need to satisfy the demands of both our OR and hospital policies.

During the installation of this software, we created two versions of our nursing notes to accommodate the somewhat different protocols associated with procedures that require sedation and those that don't. These specialized nursing notes ensure that only the appropriate data are collected for each case -- no more and no less than what is required. There's no longer any question about what information must be included in a given note. And it also means unprecedented consistency in both care delivery and case documentation.

Information at Our Fingertips

These everyday advantages are obviously very important to us -- it makes preparing for JCAHO review a breeze. During our 2002 JCAHO preparation process, instead of asking medical records to pull paper charts, I simply turned to my computer. Within minutes, I was able to retrieve all the necessary medical records. That capability alone represents a huge time savings.

In a quick time span we had armed ourselves with all the data JCAHO was looking for. From the moment we retrieve them, our records show that we have routinely gathered all the necessary information. They also show that we have routinely conducted a complete patient assessment before each procedure -- that we took the patient's history, documented whether we'd done a heart/lung sound, made note of any medications the patient was taking, and recorded the indications for the procedure.

It's hard to say exactly how long it took us to gather this information from the software; because of the system's speed, we were able to continue carrying our normal patient load throughout the preparation process, fitting data compilation in whenever we had a spare moment. It is clear we were able to complete our JCAHO preparations with very little additional time and effort.

In and Out in Less Than 60 Minutes

One JCAHO representative came in to conduct our review this time around -- a nurse. She was in our unit for less than an hour -- just a fraction of the time they used to spend poring over our records. But once she'd taken a look at our notes, she didn't need to look for any other information because the required information was ready.

We simply showed JCAHO the actual reports that we had generated that day; she was so impressed with how organized we were, and how complete and accurate our nursing documentation is, that she didn't need to ask us much more. The nurse reviewer kept emphasizing how pleased she was to see our method. She was especially impressed that we didn't have any of those handwritten notes you see in most other facilities -- notes that all too often amount to little more than scribbling.

Just imagine how nice it is to hear a JCAHO reviewer look at your documentation and make comments like "pleasing to the eye" and "a breath of fresh air!" That's the beauty of this system -- its notes are both comprehensive and completely legible.

Today our nurses are using the software on laptops in the recovery area, and on desktops in the procedure rooms. And every single one is delighted with the results. It has allowed us to gather patient data with incredible speed, which frees us to focus on our primary objective -- providing excellent patient care.

Isah Macapagal, RN, BSN, is the associate manager of the gastroenterology department at the University of Miami Hospital and Clinics.

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