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Notebooks can help your hospital ace its next JCAHO test

Nurse Leader Weekly, July 24, 2006

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It's one thing to think that you're ready for JCAHO surveyors to arrive tomorrow morning; it's another to practice being ready for them to arrive.

At Northwest Medical Center in Tucson, AZ, Director of Risk Management Annette Vince wants no surprises when survey day finally comes. So she has tested and tweaked her 300-bed hospital's survey readiness with two large-scale mock surveys. "And we'll keep testing it," says Vince, who's in charge of survey prep.

Preparing your survey readiness notebooks

Northwest Medical developed two types of continually updated notebooks that are ready to use as soon as surveyors arrive.

• One notebook that Vince manages contains all of the information that surveyors need upon arrival (e.g., an organizational chart and data sets outlined in the JCAHO's Survey Activity Guides that all accredited organizations receive).
• Separate notebooks also are kept in the departments that are required to respond to surveyors' arrival. Although contents may vary, they contain information about the activities that departments must carry out. For example, the administrative notebook has information about how to initiate the command center and prepared e-mails with last-minute survey tips that are sent out housewide.

Make sure to think of everything

Surveyors can visit any department in your organization, so include all departments in your planning, Vince says. Every department at Northwest Medical-even dietary-has a notebook with information that is continually updated by that department and ready to be used whenever surveyors arrive.

"Dietary [staff] has menus in their notebooks," Vince says, explaining that the facility's chef has developed a menu suitable to all tastes, and he gets to present it in a pleasing way in a conference room.

"If they really want to go to the cafeteria, they can, but the menu and the chef presentation is just one more thing we can do to make the surveyors' experience a good one," Vince says. Plus, "[there's] more time for the surveyors to do their work instead of waiting in line."

Editor's Note: This excerpt was taken from Briefings on JCAHO, July 2006, HCPro, Inc.

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