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Mock surveys result in Joint Commission success

Nurse Leader Weekly, April 28, 2008

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Staff at Peninsula Regional Medical Center in Salisbury, MD, are learning prepping makes perfect, when speaking in terms of hand hygiene for unannounced Joint Commission (formerly JCAHO) surveys.

Mary Williams, RN, Joint Commission regulatory coordinator at Peninsula, orchestrated three mock surveys before the unannounced survey in December 2007.She also focused on keeping staff members enthused about hand washing and disease control.

The process proved a success when Peninsula became the first hospital that didn't have a requirement for improvement for hand hygiene in 2007.

The 375-bed hospital, located 29 miles from Ocean City, MD, created a J-code to notify medical staff, managers, and supervisors when the survey or mock survey was taking place.

"Staff were familiar with this code and were trained to respond quickly," says Williams. During the practice surveys, Peninsula used executive staff members as overseers, which added tension and proved useful when the survey team arrived.

"When the real survey took place, the surveyors were in the lobby at 7:30 a.m.," she says, "We found the notice online at 7:25 a.m., so we knew for a few minutes they were [on their way]."

Editor's Note: This excerpt was adapted from the article, MD hospital avoids hand hygiene RFI, finds areas for improvement featured in the Reading Room on HCPro's new online resource center, www.StrategiesForNurseManagers.com. Get a free trial membership that will give you 30 days to "test drive" all the exciting features on the Web site.

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