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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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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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Greetings and Introductions

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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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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 Jessica_Bush@qhr.com for assistance.

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Jessica_Bush@qhr.com

(800) 233-1470, ext. 4513

For More Information Contact:

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Intended for internal guidance only, and not as recommendations for specific situations. Readers should

consult a qualified attorney for specific legal guidance.

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