Accreditation

Team approach to survey prep helps staff anticipate surveyor questions on environment of care, goals

Briefings on The Joint Commission, October 1, 2006

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

After reading this article, you will be able to

1. -list five presurvey preparation activities

2. -explain why you might have to complete an evidence of standards compliance even though you fixed a requirement for improvement issue (RFI) during survey

3. -describe some benefits of putting together interdisciplinary survey-preparation teams

Patient and system tracers played out during survey at Florida Hospital DeLand exactly how staff practiced them during their mocks.

"Not to beat my chest too much, but we did well because we were prepared," says James A. Gomez, quality manager at the 156-bed community facility that serves the Daytona, FL, area.

Gomez says his staff were able to anticipate and answer almost every question posed by surveyors because of presurvey preparation activities that included

  • audits and chart reviews completed monthly to find instances of noncompliance (e.g., unapproved abbreviations). Tabulated results were presented during a weekly JCAHO task force meeting.
  • 10-15 mini tracers each month on every unit. Gomez says these weren't onerous because nursing staff rotated the duty of completing the five-question forms. "It's good to put these questions in the hands of staff, because then they're aware of the weaknesses."
  • weekly mock surveys since the beginning of the year in anticipation of the survey. Before that, in the two years after the last regular survey, the facility held mock surveys monthly, with each one focusing on a different unit.
  • skills fairs to practice interviewing and learn about performance-improvement initiatives related to the JCAHO requirements. "We ship data out to the floors quarterly," Gomez says. "I report the good, the bad, and the ugly." Seeing the data helps staff better speak to indicators-particularly related to performance improvement-on their units during survey,he adds.
  • orientation of all new employees on JCAHO and safety issues. In addition, each year Gomez writes and prints a JCAHO and safety reference-guide booklet with survey tips. "Staff don't carry it with them every day, but they have to read it, and they have it to fall back on," he says.

    Florida Hospital DeLand put together multiple interdisciplinary teams, each with specific responsibilities, to make the many presurvey activities run efficiently and ensure proper education for everyone, Gomez says. Even the chief operating officer got involved.

    "It really is a team effort. The groups that we work with, they're excellent," he says. "You have to have support from all levels. Mock tracers included management. They'd come with me on tracers to ask questions so they'd get comfortable."

    The teams also had outlined which staff would attend each session during survey, which he says made a difference, because "it's amazing how many people will scatter when JCAHO shows up if you allow them to."

    • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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