Our triennial survey by the Joint Commission was completed last week and we did very well. I was not surprised because we have outstanding people and we have worked hard to create systems to help them do their job and provide highly reliable care. Let me thank all our team for their incredible efforts to deliver the care that we want for our own loved ones. Great job!
The surveyors found some opportunities for improvement but overall, they were very impressed. In many areas, they had no findings. In Maternal Newborn Health (MNH) the nurse surveyor from the Joint Commission reviewed eight charts and found no issues to correct!
Every Joint Commission visit to MNH starts with the review of a patient who has had a vaginal delivery and one who has had a cesarean section. There is also a chart review of a high-risk patient with an obstetrical or medical complication.
In 2020, the Joint Commission introduced two new standards to address complications related to maternal hemorrhage and severe hypertension. Our nurses, nurse educators, and Epic analysts worked together as a team to add functionality to Epic to meet the new standards. This was a collaborative process where input from all team members was invaluable. The goal was to assure patient safety and decrease the risk of complications, while ensuring seamless integration with the workflow. The surveyor focused on these new standards during the chart reviews in Labor and Delivery.
During the chart reviews, the Labor and Delivery nurses were able to highlight two new areas of build in Epic that address the new standards. The Labor and Delivery and Mother Baby staff now use a Postpartum Hemorrhage Assessment tool that identifies the patient’s risk of hemorrhage from admission through the postpartum period. One of the highlights of this tool is that once the provider enters the necessary documentation to calculate a hemorrhage risk score on admission, Epic continues to calculate the risk based on specific criteria in the background without the nurse having to re-enter documentation at set intervals. The score recalculates automatically and is highlighted in the Storyboard and several other areas in Epic.
The Labor and Delivery nurses were also able to highlight the care that they provided for a patient with a hypertensive emergency. The Epic team and clinical end users worked together to build a new comprehensive order set for this type of event as well as new patient assessments. The staff did a great job of navigating through this complex patient chart.
I want to congratulate Gretchen Bell, RNC-OB, C-EFM, our Application Coordinator/Analyst Team Lead EPIC, our Labor and Delivery nurses, and all members of our MNH team for this fabulous achievement, and for working together to continually improve patient care.
I also would like to thank everyone for their hard work, collaborative spirit, and commitment to patient safety. It was evident to our survey team that GBMC is a highly reliable, patient-centered organization.
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