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Conducting and documenting meetings

Ambulatory Surgery Reimbursement Update, March 17, 2005

You may be expected by your organization to give every employee an opportunity to participate in a monthly staff meeting. If logistics preclude an in-person meeting each month, broad-based communication can be achieved for off-shift or casual workers with a meeting minutes notebook, which all staff must review and initial. However, this should not replace all in-person meetings.

A monthly staff meeting is not a regulatory or accreditation requirement. The JCAHO requirement dictates that "leaders hold staff accountable . . . [and] communicate . . . goals to all staff." As you consider your flow of communication, make sure that you can answer the following questions you may be asked by a JCAHO surveyor, state department of health nurse, or other regulator:

• How do you let your staff know the quality issues and goals for the department?
• If I interview staff, will they know what you are working to improve and where the current problem areas are?
• How do you include staff input as you set quality or performance improvement goals?
• Can every employee describe quality control responsibilities?
• Do employees feel empowered to stop a patient care process if they feel it is unsafe or does not meet your criteria for quality?

Avoid pitfalls

The daily challenges of running a cost-effective operation may easily push a staff meeting to the bottom of the priority list. Patient care must come first, the medical staff need results now, perhaps there are some staffing shortages, and so on. The following tips will keep you on the right track:

• Ensure that the meeting has real value. Structure substantive agendas so that meetings are not merely formalities, but actually get work done.
• Conduct the meeting efficiently. Meetings don't have to last an hour. Much routine information that doesn't need discussion can be assembled and posted in a staff report room or other nonpublic location. Focus the meeting agenda on items that require action, and refer to the routine items staff must review later.
• Include the right people, and start and end on time. Don't waste anyone's time; begin on time and ensure that everyone is there who needs to present information.

Designing effective communication

Check with your organization's quality/human resources department to determine whether there are specific requirements in place for your setting. If there are no formal requirements for meeting structure, frequency, and documentation, consider the following recommendations. If your organization does have such requirements, the recommendations below can easily be tailored and incorporated into your structure to enrich the content and help you to conduct and document meetings efficiently and effectively:

• Obtain your organization's policy, procedure, or guideline on how often to conduct staff and quality meetings, mandatory content or agenda structure, and required/recommended formats for meeting documentation. Learn who needs copies of your minutes--perhaps your supervisor or the quality department? Also find out how long you should keep copies of your minutes and the underlying data.
• Devote a portion of each monthly staff meeting to quality. This will not always include a review of specific indicators and measurement data; however, the manager should convene the meeting as a quality management or quality improvement review session. The subject material will vary depending on the department.

This excerpt was taken from the HCPro, Inc. book Performance Improvement Basics: A Resource Guide for Healthcare Managers by Cynthia Bernard, MBA, MSJS, CPHQ.

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