News and Views for Healthcare Accreditation Professionals

Archive for June, 2011

Doctors acting as interpreters: WHAT SIG SAYS

Question: We have physicians who speak Spanish as their native language, and have received medical education in the country of their birth. 

Would it be acceptable for the physician to provide foreign language education (patient centered communication standards) and translation for patients who speak the same native language?

Would this be acceptable for nurses to do this?

Answer: Thank you for your inquiry. The Joint Commission finds the use of staff for interpreter services acceptable but would require the organization to ensure the competency of the individuals providing these services. The organization would also define the qualifications for these individuals. The organization may also consider including certification, conducting an assessment of language proficiency in both English and the targeted language and promote ongoing training. Please review standards RI.01.01.03 EP 2 and HR.01.02.01 EP1. You may also want to review a resource provided by the Joint Commission which addresses this issue entitled, “Advancing Effective Communication, Cultural Competence and Patient and Family Centered Care A Roadmap for Hospitals” . This manual is available on the Joint Commission website for all accredited organizations. Please review I have entered the link below:


Pre-labeling empty syringes acceptable

TJC has backed off on the requirement to NOT pre-label containers (NPSG 3).  However, from the wording it is very clear that the policy must actually permit it and that it is not just a random and inconsistent event.

Director of Anesthesia Job Description

Just posted to is a Job Description for the Director of Anesthesia services which may or may not be the Chief of Anesthesia.

For those COP Part A hospitals that are surveyed that do not have anesthesiologists, just rewrite the qualifications to what is appropriate.

In larger hospitals, the Chief of Anesthesiology may not always be the Director of Anesthesia services especially in large academic facilities.


Writing Orders in advance of procedures/anesthesia

Prior to surgery, anesthesiology assesses the patient while in the holding room. Based on that assessment, the anesthesiologist knows that for pain relief in the recovery room he is going to prescribe, for example, Dilaudid, for the patient. The hospital uses a post-operative recovery order set, which has on it various medications for post-operative pain. If Dilaudid doesn’t work, the order set allows the anesthesiologist to choose the next med, likely Morphine Sulfate. To initiate all of this, is it acceptable for the Anesthesiologist to sign/date/time the post-operative recovery order set when he does the pre-operative assessment – which is prior to the surgery?

It is not acceptable to write and sign orders prior to performing the procedure. In the post-op note situation the practitioner might start the note prior to the procedure, leave it unsigned and after the procedure edit/update as necessary and sign, date and time it to clearly indicate completion after performance of the procedure or at the time the order is needed.

In an orders situation, there would need to be clear evidence that the order was given or activated after the procedure or at the time the order is needed by the patient. This can again be a signature, date and/or time or if your “activation” process can clearly indicate that it was activated by the physician at the appropriate time, not in advance, then an electronic signature or activation would likely be acceptable. It could be activated only by the person giving the order, i.e., the physician, dentist, etc.

In most states nurses or other non-independent practitioners under their scope of licensure cannot determine when an order is required to be activated. We see this issue with preprinted and pre-approved standing order sets. There must be a patient specific order from the physician for the use of the standing order set at the time the set is to be implemented or is determined to be needed by the patient.

Wrap those laryngoscope blades!

There seems to be a new favorite out there with surveyors.  For years we (anesthesiologists) have been tossing laryngoscope blades into the top drawer of anesthesia carts unwrapped.  These were frequently right next to the Mounds Bars and Butterfingers so that blades would have a pleasant flavor for patients while they were intubated.  (JUST KIDDING!).

Recently surveyors are expecting laryngoscope blades to be wrapped after high level disinfection regardless of the method.  A recent phone call with Louis Kuhny at the Joint Commission cited a current CDC requirement related to prevention of Pneumonia.

In any case, its time to practice safe intubations and wrap those blades!

TJC’s Rationale: The CDC’s 2008 Disinfection & Sterilization Guideline does not address the packaging issue.  Therefore TJC looked at other CDC Guidelines and a prior one, “GUIDELINES FOR PREVENTING HEALTH-CARE-ASSOCIATED PNEUMONIA, 2003” does have a specific recommendation which is provided below that states, “…after disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items in the process (308;310). CATEGORY IA [Strongly recommended for implementation and strongly supported by well designed experimental, clinical, or epidemiologic studies]

News and Views for Healthcare Accreditation Professionals

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Stephen M. Dorman, M.D.