Nursing

A variety of preparation activities can help with an unannounced JCAHO survey

Staff Development Weekly: Insight on Evidence-Based Practice in Education, September 29, 2006

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During Florida Hospital DeLand's JCAHO survey, patient and system tracers played out exactly how staff had practiced them during their mocks.

Quality manager James A. Gomez says his staff at the 156-bed facility 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."
  • 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.

To learn more, go to Briefings on JCAHO (BOJ). For the cost of just three stories, you can get the entire October issue of BOJ. Click here to choose between the PDF and HTML versions for just $30. Subscribers to the online version of BOJ have free access to this article. Subscribers to the print newsletter can find this article in their October issue.



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