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Arm yourself with nine survey readiness secrets

Accreditation Connection, September 10, 2004

How did Anaheim (CA) Memorial Medical Center stay survey-ready day after day, and how will it remain ready year after year?

According to Mary Kingston, RN, MN, CPHQ, executive director of performance improvement and patient safety, it's all a matter of low-key, continuous grassroots education.

Instead of mandatory meetings, use creative methods to educate staff on news from the JCAHO Web site and in the media and to reinforce the National Patient Safety Goals. Some of the methods the hospital used included the following:

1. Team leaders: Kingston assigned leaders to every chapter of the Comprehensive Accreditation Manual for Hospitals in order to assess the hospital's compliance with the standards and what it could do to fix potential problem areas.

 
2. Posters: Kingston placed posters highlighting the National Patient Safety Goals in high-traffic areas, such as break rooms.

3. Games: The hospital created games, including one called Joint Commission Trivial Pursuit.

4. Quizzes: Team leaders conducted weekly quizzes to reinforce hospital policies with prize awards.

5. Pocket cards: Managers gave staff educational pocket cards.

6. Environmental care rounds: Teams went on rounds every two weeks and caught a number of problems.

7. Mock tracer surveys: Group managers talk with staff from different departments during monthly tracers so staff are comfortable talking with anyone.

8. Books: Anaheim Memorial published its own books, including a Survivor Guides series that provided information on how to be survey ready.

9. Parties: The hospital sponsored JCAHO tailgate sessions. These events involved either a free lunch or snack and show that consisted of vignettes from the JCAHO tracer methodology videos.

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