An important announcement regarding Virtua's recently completed
Joint Commission survey:
As you may be aware, Virtua recently completed its triennial Joint
Commission survey. Overall it was a very successful survey, but a few areas
of improvement were identified by the Joint Commission. The areas which
require action are identified below and Virtua has 45 days to develop a
corrective action plan and audit for the success. The medical staff’s
cooperation is crucial and the Divisional Medical Executive Committees will
be receiving regular reports regarding physician compliance. Specifically,
the standards you can positively impact are:
1. TIMING AND DATING ALL ENTRIES INTO THE MEDICAL
RECORD – This was a heavily cited area during the JC survey. All
entries into the medical record need to have a time and date. This includes
all progress notes, orders, history & physicals, consults, operative notes,
etc…This is a CMS requirement and both the hospital and individual
physicians may be asked to return Medicare reimbursements if time and
date are not included in documentation.
2. UNIVERSAL PROTOCOL AND TIME OUTS – A time out must
be performed for every invasive procedure regardless of where the
procedure is performed and should include all who are participating in the
procedure. All members of the team must suspend their activities to the
extent possible, to participate in the time out. Procedures outside of the OR
are documented on the Universal Protocol Form.
3. AUTHENTICATION OF VERBAL ORDERS – All
verbal/telephone orders must be signed, dated, and timed within 48 hours of
the original verbal/telephone order. This is also a CMS requirement.
4. THERAPEUTIC DUPLICATION – Physician were cited for
ordering multiple medications for the same condition (pain, nausea, etc.) If
multiple medications are ordered for the same condition a reason must
accompany the order and instructions of when to use one drug as opposed
to the other must be given. This issue most commonly occurred with the
preprinted order forms. As a result they have been edited to clarify which
drug should be given. In the event a duplicate drug is ordered pharmacy will
call the physician for clarification.
5. PRN MEDICATIONS WITHOUT AND INDICATION – This
was a frequently encountered issue during the survey. All PRN medications
must have an indication. A list of commonly used PRN medications and their
default indications has been developed and approved by P&T. If a reason
is not given for a drug not on this list, the drug will not be dispensed by
All of these changes are being instituted in the best interest of our
patients. These areas will be audited over the next few months and the
results reported back to the respective Medical Executive Committees.
Thank you in advance for your cooperation and attention to these issues.
|Jim Dwyer, DO
Executive Vice President
|Stephen J. Pilipshen, MD
|Stephen P. Gadomski, MD