By Amy Antonacci, MSN, RN
Josephine is a vibrant wife, mother and grandmother. At seventy-eight, she walks three miles each day and does chair yoga twice a week with friends. She is in relatively good health, takes only a few medications, and sees her primary care physician twice annually. Josephine’s biggest health obstacle is her left hip, which causes her almost constant pain when walking and even when she is trying to sleep. It has started to negatively affect her ability to remain active. She has made the decision to have a total hip replacement and is excited about the prospect of returning to her usual physical activities.
Josephine’s hip replacement is scheduled in six weeks at the local hospital by an orthopedic surgeon who is on staff at the hospital. Let’s follow the links that connect CMS and ACHC requirements before, during, and after her surgery, to protect her rights as a patient and promote her safety.
BEFORE ADMISSION
Josephine’s physician has been on the medical staff at the hospital for 12 years (03.00.02 Periodic Appraisal of Members, 03.00.07 Duties and Responsibilities to Patients, 03.01.02 Medical Staff Bylaws: Approval by Governance, 03.01.15 Application and Reapplication Requirements, 03.15.01 Ongoing Professional Practice Evaluation). Josephine sees her physician in an office visit 28 days before her surgery to review the surgical procedure and complete a history and physical examination (03.01.07 Medical staff bylaws: History and physical requirement). The office also schedules an appointment at the hospital’s perioperative clinic (18.00.05 Pre-anesthesia evaluation) to see the anesthesiologist who will evaluate her overall health status and develop the anesthesia plan for surgery.
PREOPERATIVE REGISTRATION
Josephine is anxious on the morning of her surgery. Her husband has dementia, so her daughter will be by her side as well. Josephine hopes she will be permitted to have them both with her whenever possible. A registrar provides Josephine with a copy of the hospital’s patient rights brochure (15.01.00 Notice of patient rights, 15.01.02 Notice and promotion of patient rights) and assures her that both her husband and daughter can accompany her to the same day surgical area (15.01.12 Visitation rights). Once she is settled, a nurse meets with Josephine and her family to obtain important information. Josephine confirms her date of birth, and an identification bracelet is placed on her wrist (15.03.05 Identify patients correctly). The nurse asks her if she has a living will or durable power of attorney for health care; Josephine has both and provides copies (15.01.05 Advance Directives).
Josephine will sign an informed consent prior to entering the OR (30.00.11 Surgical Informed Consent) and her physician and anesthesiologist will update her H&P and review her pre-anesthesia evaluation to verify that her health status has not changed warranting a delay in surgery (18.00.15 Pre-anesthesia evaluation, 30.00.10 History and physical and update to the history and physical).
PERIOPERATIVE PROCEDURES
Soon enough, it’s time for Josephine’s surgery to begin. She’s unaware of all the hospital does to create a safe environment for her procedure. The space and equipment being used are all carefully managed (11.00.01 Physical environment, 11.01.02 Building safety, 11.04.01 Written fire control plans, 11.04.04 Approval by state and local fire agencies, 11.05.01 Medical equipment and systems: Maintenance, 11.06.03 Water management plan, 11.07.01 Adequate facilities and supplies, 11.07.03 Ventilation, light, and temperature controls).
The hospital also has taken significant steps to protect her from infection that can negatively affect her ability to recover quickly and smoothly. The hospital’s Infection Prevention and Control (IPC) Program includes every department Josephine and her family will interact with (07.00.00 Infection prevention and control and antibiotic stewardship). All cleaning processes for the physical environment, equipment, and surgical instruments, were reviewed and approved by the IPC Committee and align with nationally recognized guidelines (07.02.08 Surgical site infections, 07.04.01 Decontamination and sterilization policies, 07.04.07 Preparing, assembling, wrapping, storage, and distribution of sterile equipment and supplies, 07.05.02 High-risk cleaning procedures). The staff have been trained in proper techniques for hand hygiene (07.02.05 Hand washing guidelines) and the PPE (07.02.04 Personal protective equipment) that safeguards both patients and staff. Countless mitigation measures are in place to reduce the risk of Josephine acquiring an infection (07.02.01 Risk mitigation measures for infection prevention) and a multidisciplinary team conducts regular surveillance of the environment to validate the correct processes are followed (07.02.03 Environmental surveillance).
Multiple surgeries are scheduled on the day of Josephine’s hip replacement, but Josephine’s and her family are focused on her personal well-being. Surgery represents a high intensity environment. There are many moving parts occurring simultaneously and each one is extremely important. That can create conditions conducive to potential error and this is why some of the most important steps for Josephine’s safety are about to occur. She will be cared for during surgery by a highly-trained team. Nurses and technicians with defined duties (30.00.03 Scrub nurse, 30.00.04 Circulating nurse) will assist and document during the procedure. Numerous required policies detail the processes that will ensure a standardized and safe procedure for Josephine (30.00.09 Standards of practice). Just before receiving anesthesia, Josephine will participate in a time-out (30.00.14 Operative site verification). Josephine, her surgeon, and the entire surgical team, will pause all activity to verify that she is, in fact, Josephine, and to confirm the left hip as the operative site. This intentional time-out allows everyone, including Josephine, to validate that the surgical plan is completed on the correct anatomical side. Detailed documentation will be completed by her surgeon, the anesthesiologist, and the clinical staff (30.00.19 Operative report, 18.00.06 Intraoperative anesthesia record).
POSTOPERATIVE PROCESS
Once the procedure is complete, Josephine will be transferred to the PACU and assessed and monitored by the staff and anesthesia team (18.00.07 Post-anesthesia assessment, 30.00.17 Postoperative care, 30.02.03 Nursing care: Post-anesthesia, 30.02.06 PACU required equipment, 30.02.13 PACU discharge criteria). Once she is ready for discharge from the PACU, she will be transferred to the hospital postoperative unit and her care will continue as additional regulatory requirements support her ongoing recovery.
Sometimes we have a negative outlook when it comes to “requirements” in health care. They seem cumbersome, difficult to operationalize or even unnecessary. If we shift perspective to consider these requirements from the patient’s point of view, they represent reassurance, focus and care. The partnership among hospitals, ambulatory surgery centers, accrediting organizations like ACHC, and patients like Josephine, promotes standardization for excellence in patient care and outcomes. Almost everyone will be a patient at some point in their life. Let’s recommit to the important and necessary work that will ultimately support our care.
– Amy Antonacci, MSN, RN is a Standards Interpretation Specialist for acute care and critical access hospital accreditation with ACHC and serves as an ACHC Surveyor. Before joining ACHC in 2023, She spent 13 years as CNO for an acute care hospital with system-wide responsibility for two years. She has been a nurse for 35 years and has a passion for patient safety.
