We were surveyed this Fall. No matter what JCAHO says, what is covered in
the formal survey depends in part on the interests of the individual
surveyors that day. Our surveyors were also interested in Pain Assessment
and Multidisciplinary Documentation. We have been working for months on a
consolidated version of charting and just about everyone charts in Progress
Notes, including the LCs.

We were not questioned as extensively as you were about LC coverage. We
have 3 full time LCs and average 500 births a month. we cover 5 1/2 days a
week and alternate being on-call on Sundays for emergencies. We do more
than work with the moms. We also have rewritten P&Ps, are rewriting Patient
Ed handouts on a 4th grade level (meaning we can't use anything already
written by anyone), teach Discharge Classes, take consults at the clinic
next door, and participate in Peds, OB, & NICU Collaborative and Process
Improvement Committees, the P&P Committee, and the Maternal-Child Managers'
Meeting; teach at staff meetings, keep a running book on our
accomplishments - to prove we have been doing something - and teach the
Residents about breastfeeding. Much of this can never be done if only one
of us is in the hosp at a time, and none of it can be done at night or on
weekends. Future plans have us going to the other 12 clinics, but that's
waaaayyy in the future. We also collect Initiation & Continuation data in
an effort to show we are having some effect on those rates.

Our JCAHO reviewers were accepting of our activities and overall, our hosp
came out with a final score of 92! One key is to answer exactly what is
asked. Keep it simple. Don't elaborate beyond the specific question, and
defer to your superiors when necessary. During our Mock JCAHO, we got
dinged for out of date formula on the shelves. You can be sure the 3 of us
are regularly checking that, delightedly pouring old formula down the
drain, & marking all bottles with red tape that are within one month of
expiration. Our 'fridges & freezers are dedicated to HM only and are
checked daily for temperature. Our policy does include use of gloves when
handling HM, in spite of what OSHA etal have said. Our Infection Control
lady visibly shivers at the thought of my getting a few drops on my fingers
when assisting with a latch, even though I always wash before & after.

--- Phyllis Adamson, IBCLC
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