HOSPITAL GETS OVERALL GOOD GRADE; AGENCY REQUIRES SOME CHANGES.

Byline: Karen Maeshiro Daily News Staff Writer

Antelope Valley Hospital received a better-than-average grade from an independent accreditation commission, but the agency found fault with the medical center's documentation and infection control.

The Joint Commission on Accreditation of Healthcare Organizations, which accredits 80 percent of U.S. hospitals, gave the hospital an overall rating of 93. The average score is 92.

``We did exceedingly well,'' board president Dr. John Manning said. ``In January they raised the standards. We got a 93 compared to 87 three years ago with lower standards. We are very proud of that.''

The hospital was cited for deficiencies in six areas, four because of insufficient documentation in the area of patient and family education. Deficiencies are noted with scores of 3 for partial compliance, 4 for minimal compliance and 5 for noncompliance.

The hospital scored a 4 in the area of patient data and information because staff members had failed to get physicians to sign off on verbal orders that they called in within the required 48 hours.

Of the 18 records pulled by JCAHO surveyors, 10 did not have the signatures within the 48-hour time period, said Bonnie Daniel, assistant vice president of nursing practice.

To correct that problem, floor nurses and medical records staff will flag charts with ``purple sticky'' notes to alert doctors that their signatures are needed, Daniel said.

The hospital scored a 3 in the area of infection control. JCAHO surveyors found that the disinfection process for bronchoscopes - tubes that are inserted down the throat to look in the lungs - did not follow manufacturer's recommendations.

Daniel said the hospital had been using national guidelines for disinfection. Staff members will now go beyond meeting the manufacturer's guidelines and begin sterilizing the equipment, she said.

The hospital scored four 3s for insufficient documentation in the area of patient and family education.

In some instances, staff did not check boxes on charts to indicate that they had given information about medication and how to administer it; that they had informed patients about dietary directions when using certain medications; that they gave out information about community resources; and what educational instruction was given to the patient, Daniel said.

Workers were not checking boxes because the forms were too complicated, so the forms are being simplified, Daniel said.

``We are in the process of revising patient education forms and standardizing all teaching tools or information handed out to patients,'' Daniel said.

Daniel said the hospital has six months to make the improvements to come into compliance.

According to the latest figures available from 1997, 53 percent of the hospitals that JCAHO accredited received a score of 93 or higher, said officials with JCAHO, a private, nonprofit organization founded in 1951.

Accreditation by the commission is generally recognized as a ``seal of approval'' and is sought by hospitals to qualify for reimbursements for Medicare or from other insurers.

The organization, based in Illinois, usually surveys hospitals every three years, and it awards accreditation after it evaluates hospitals on such issues as safety, services and quality of care.

Antelope Valley Hospital received its score after the commission surveyed the hospital during a four-day visit in April.

In a separate report card, the hospital's home health program scored an overall 92 from the commission and was given accreditation with recommendations for improvement.

The commission has seven levels of accreditation, the highest being accreditation with commendation, followed by accreditation; accreditation with recommendations for improvement, which is what Antelope Valley Hospital received; conditional accreditation; provisional accreditation; preliminary accreditation; and no accreditation.

In 1997, about 85 percent of hospitals fell into the same category as Antelope Valley Hospital. A total of 11 percent received the highest level, records show.

The rating given to Antelope Valley Hospital ``is given to a hospital that generally meets the standards but does not meet certain important standards in at least one performance area,'' according to a JCAHO report. ``Most hospitals fall into this category. In order to remain accredited, they must meet the identified standards within a specified period of time.''