ThedaCare Regional Medical Centers –Neenah (December) and Appleton (end of January 2022) are in the window for their triennial accreditation surveys. ThedaCare Medical Center Shawano is due by May 2022.
During the surveys, the surveyors will be interacting with staff, providers and patients. A tracer methodology is utilized by the surveyors which traces patients through all points of their stay (ED, OR, PACU, ICU, Surgical Services to discharge). The surveyors are looking at hand-overs between departments as well as hand-over/communication between team members.
Other areas of focus for surveyors include:
- Placement of Orders in the EMR. Providers should not be giving orders via secure chat.
- Medication Orders in general. Two areas of focus are:
- Therapeutic Duplication- multiple pain medications without specific directions. Ex. 2 medications ordered for “severe” pain, but no instruction on which one to use first. State of WI licensing for nurses does not allow them to pick one over the other. The provider must indicate!
- PRN medications without an indication listed. We have worked hard to incorporate in the order sets indications for the most commonly ordered PRN medications. Even if medication only has one indication, it must be listed in the order. Ex. Medications for constipation need to have indication listed, and if one or more is ordered would need instructions. For example, give fleets enema for constipation unresolved form Bisacodyl Suppository.
- Timing of History and Physicals, Operative Reports, Procedural Notes and Discharge Summaries.
- Informed Consent process – prior to any procedure, surgery or blood transfusions.
- Advanced Care Planning and presence of Advanced Directives.
- Provider Consultations being conducted within timeframes outlined in policy.
If you have any questions regarding the upcoming surveys, please reach out to the unit managers for clarification or email michelle.bastian@thedacare.org
Thank you
Mbonu Ikezuagu, MD, FACP, CPE
Chief Quality Officer, ThedaCare
