Accreditation

Greeley Reflections

Accreditation Connection, December 14, 2009

Gray matters: Red alert

Part 5 of 5

For those of you charged with managing the Periodic Performance Review process, I wanted to share some thoughts based on evaluations I’ve been running into lately as I travel the highways and byways of this great nation of ours.

I, not infrequently, encounter what I (in my Boston vernacular) would describe as hahd mahkahs (hard markers to you in other parts of the world). For these folks, a score of full compliance is as unattainable as nirvana or a zero-calorie double cheeseburger. Now, I will absolutely agree that there is always (one of the few times I would even attempt to use always as a descriptor) room for improvement. There is no such thing as a risk-free environment and hasn’t been for a very long time.

But that’s okay, and it’s okay if we do not have perfect processes – the management of the environment of care, as it is with most risk management undertakings is one of continuous tweaking (in the industry, this is known as process improvement) – it’s all about getting better (which has a strange commonality with the purpose of healthcare, no?). The Joint Commission standards, particularly the Emergency Management standards, are full of requirements for organizations to identify “how” they do things – really – you can look it up. Just check out the EM chapter, I promise I’ll wait for you to get back.

See what I mean? Develops and maintains, describes how, identifies – these are the “requirements.” Nowhere does it say that things have to be done perfectly – we’d never be in compliance. It’s all about identifying improvement opportunities and then identifying strategies to makes those improvements “real.” Even then, there are strategies that will fall by the wayside because they weren’t the right move, or at the right time, or something like that. This, ladies and gentlemen, is what is known as experience, which is how the human species tends to learn.

Make the most of those teachable moments and your Environment of Care will be just fine!

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