Accreditation

MD hospital avoids hand hygiene RFI, finds areas for improvement

Briefings on Accreditation and Quality, April 1, 2008

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Multiple mock surveys prove to be one of the best ways to prepare staff members and hospital systems for unannounced Joint Commission surveys.

Mary Williams, RN, Joint Commission (formerly JCAHO) regulatory coordinator at Peninsula Regional Medical Center in Salisbury, MD, orchestrated three mock surveys before the unannounced survey in December 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.

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