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Donna Wood, RN, Practice Leader, Clinical OperationsChris Martorella, RN, Manager, Clinical Operations
Survey Readiness Overview: Failing to Prepare is Preparing to Fail
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Evaluate this Session!
Please help us improve our educational sessions by completing an evaluation of this program.
You will receive an email with the link to the online evaluation and recording of this Webinar within two business days.
To receive credit for this program, please complete the evaluation form as instructed in the email. You have ten days after receipt to complete the online evaluation.
If you are unable to complete the evaluation within the ten-day deadline, your certificate will be delayed. Please contact [email protected] for assistance.
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As leader of QHR’s Clinical Operations consulting practice, Donna Wood oversees the development and execution of strategies for hospitals and health systems that guide improvement initiatives in Clinical Operations, Care Coordination, Patient Safety, Nursing Excellence, Performance Improvement, and Regulatory Compliance.
Donna Wood, RN, BSN, MHA, MRMPractice Leader, Clinical Operations
With more than 30 years of healthcare experience, Donna effectively delivers quality turnaround engagements and clinical transformation strategies to her clients. Prior to joining QHR, she served in various leadership and hospital consulting roles, including: clinical experience in Critical Care at Brigham & Women’s Hospital in Boston, from staff nurse to VP of Critical Care Services and director in Deloitte Consulting’s Healthcare Practice, with a focus on Performance Improvement.
A pioneer in Patient Safety, Donna has participated on several Institute for Healthcare Improvement (IHI) teams, including serving as faculty for IHI courses. She was also an early participant in the AHA Patient Safety Fellowship program.
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Christopher Martorella firmly believes that success in Patient Services is founded on educated and mutually supportive nursing/medical teams, and an ongoing commitment to identifying and resolving root causes of patient dissatisfaction. To this end, much of his work focuses on creating, implementing and evaluating programs that increase
Christopher Martorella, MSN, RN, NEA-BC, CENPManager, Clinical Operations
competencies and drive quality measures; patient, physician and employee satisfaction; and profitability.
Chris brings more than 25 years of healthcare management experience to QHR and its hospital clients. development. With a background in Critical Care Nursing, he has worked in community hospital and academic medical centers and has served as staff nurse through Vice President and Chief Nursing Officer.
Double boarded in nursing administration, Chris received his BSN from Florida State University, an MSN from the University of Florida and is currently enrolled in the DNP program at the University of Central Florida.
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Get Familiar with the Survey Process
Obtain a sample of a typical survey agenda (available on your TJC extranet site)
Review the various activities Patient care tracers, system tracers, document
review, daily briefings and surveyor planning Familiarize yourself with the standards that will be
covered during the focused sessions and tracers as well as the duration of each session
Use your resources (account execs, hospital association)
Survey Process
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Staying Educated
Subscribe to regulatory newsletters and bulletins from the Joint Commission The Source EC News Perspectives
Share information with leaders and staff that are impacted
Participate in webinars and conferences aimed at keeping facilities updated on standards
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Making Regulatory Fun!
Develop an annual Joint Commission fair Encourage participation with prizes Develop fun educational activities
oCreate a “patient room of horrors” with multiple safety issues and see how many issues staff can identify
oCrossword puzzles, word finds and quizzes designed to impart regulatory information
o Various booths with critical standard manned by leadership
Plan fun activities for Patient Safety Week as well (another venue to reinforce regulations)
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2012Keep Policy Manuals Up To Date
Update policies as regulatory standards change
Assure that appropriate staff are educated to the changes in policy
Keep rosters of staff attendance
Build policies that are multidisciplinary in nature with teams from each area impacted
Example: Plan for the provision of care
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Making It Easier on Survey Day
Maintain Joint Commission readiness manuals
Key policies that the survey team will want to review prior to starting tracer activities
Supportive documentation should also be contained in these manuals
Remember this information will serve as the “first impression” that the survey team develops about your organization
1f i r s tm p r e s s i o n s
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Maintaining PI Teams
Assure that Performance Improvement teams are making progress
Use the facility’s overall quality monitoring committee to charter and monitor the progress of teams aimed at improving regulatory compliance
Consider dividing up chapters with different leaders across the organization Allow them to choose team members Include front line staff
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Keep Readiness Activities Robust
Environment of Care rounds Not just for Plant Ops and Housekeeping staff This is a great multidisciplinary vehicle for assessing
multiple standardsoEOCoLife Safetyo Infection Control and
PreventionoClinical standards
Include Infection Control, departmental leaders of the areas being surveyed and include staff!
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Patient Level Readiness
Nursing, case management and the other clinical disciplines should be meeting to review patients for length of stay (LOS) and discharge planning Consider adding utilization functions Include pharmacy, dietary,
therapy, respiratory and chaplaincy
Frequency of meetings should be based on average LOS
Document meeting results and changes in care plan in the medical record
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Hourly Rounding
Nursing should be conducting hourly rounding
Evaluate for 4 Ps
Associated with decreases in
oFalls and pressure ulcers (hospital acquired conditions)
oCall lights for bathroom and pain (increases patient satisfaction)
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Patient Rounding
At the minimum by nursing leadership but senior leadership involvement is preferred
Learn about issues that are of concern to your customers (patients)
Monitor for regulatory issues
Opportunity for recognizing staff
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Mock Tracer Activities
MultidisciplinaryCover as many standards as possibleUse checklists to follow up on
issuesAll shiftsAll departmentsOn a monthly basisInvolve staff by asking key
questionsRemember: second generation tracers!
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Don’t Forget Patient Safety!
Patient safety goals should also be included in the mock tracer activities
“Hanging out” in the nursing station is a great way to evaluate hand-offs between disciplines and communication between caregivers
What is your process for critical lab value communication?
Monitor medication passes for patient identification and hand washing
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More on Patient Safety
Pay careful attention to non-surgical settings (Radiology, Special Procedures, med/surg) for compliance to: Labeling of medications and syringes during
procedures Completion and documentation of time out
Must demonstrate similar standards of care throughout the organization
Go to the pharmacy and ask nursing to open the medication cabinets. How are LASA and high risk medications handled? Policy posted?
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Conditions of Participation
Don’t forget about monitoring to make sure you are meeting the A-B-Cs of COPs
Have you notified TJC of any new services?
Have you added any off site departments that should be included in the survey process?
Has there been a change in the CEO?
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Annual Review
Perform a review of all standards and how the hospital meets or exceeds the requirements
Remember to include each element of performance
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Keep Information in Front of Staff
Post survey readiness information Posters in patient care areas
Bulletin boards
Streaming television
Electronic bulletin boards
Pay check stuffers
Laminated cards to attach to ID badges
Cafeteria table tents
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Transparency
Information about compliance rates and performance improvement
Wave of the future
Foster a spirit of competition which may positively impact compliance
Assists staff in being able to speak to quality and performance improvement when questioned by surveyors
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Consider Survey Complexity
If complex, your facility may surveyed under multiple accreditation programs and standards
Examples: Acute Care, Homecare, Long Term Care, Behavioral Health
Prepare a document that cross references each set of accreditation programs Include the name of main contact and phone number
for each of the programs Note: The regulatory leader cannot be everywhere
at once
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Prepare Staff for Survey Complexity
Staff and leaders should have access to the current standards in their accreditation manuals
Some support departments (i.e. Therapy Services and Pharmacy) will participate across one or more accreditation standards
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Watching and Waiting…
With rare exceptions, surveys will be unannounced
Stay in touch with local colleagues to gain insight into surveyor patterns (i.e. State surveyors)
Designate a staff member to check the TJC website daily
CONSTANT survey readiness is key
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Plan for the Arrival Process
Develop a procedure that outlines what should be done and by whom when surveyors arrive
Staff at hospital entry points should be fully competent on this process Who do they contact first, second, third? Provide office extensions and cell phone numbers
(with second and third back-ups) Assure that surveyors are positively identified (picture
IDs) Notification of the rest of the hospital
Drill this process
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Readiness Guide
Surveyor Arrival Responsible Staff Comments
Greet surveyor(s)
Verify identity Look at picture ID to ensure they arefrom the accrediting agency
Ask them to wait Location:
Validate authenticity of survey (if you have this option)
Contact: ____________________Phone number:_____________(staff contact who has this ability/authority)
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References
Survey Activity Guide for Health Care Organizations (2012). The Joint Commission. Accessed from the web on March 15, 2012: www.tjc.org
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Upcoming ProgramsUpcoming CSR Webinars
IT Workflow: Getting Nurses Back to PatientsApril 24, 2012 2:00 p.m. CST
CSR webinar: Emergency Preparedness – Contingency Planning for Whatever HappensMay 16, 2012 11:00 a.m. CST
CSR webinar: New Joint Commission Standards (Clinical and Environment of Care)July 18, 2012 11:00 a.m. CST
CSR webinar: Be Prepared to Meeting National Patient Safety GoalsSeptember 19, 2012 11:00 a.m. CST
CSR webinar: Environment of Care – Issues You Should Plan to AvoidNovember 14, 2012 11:00 a.m. CST
Register at www.QHRLearningInstitute.com
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Evaluation Reminder!
Thank you for joining us today. We value your feedback and hope that you will take a few minutes to evaluate this program so that we may continue to improve and bring you the quality educational programming you expect.
You will receive an email with the link to the online evaluation and recording of this Webinar within two business days.
To receive credit for this program, please complete the evaluation form as instructed in the email. You have ten days after receipt to complete the online evaluation.
If you are unable to complete the evaluation within the ten-day deadline, your certificate will be delayed. Please contact [email protected] for assistance.