Accreditation Field Report

Surveyors zero in on emergency preparedness

Disaster planning is critiqued

During a January 2006 survey at Baylor All Saints Medical Center at Fort Worth (TX), there was an additional focus on disaster planning during the environment of care (EOC) session, reports Paula Chaloupka, MSN, RN, director of care coordination. "This provided us a great critique of our disaster planning process," she says.

Because of the timing of the mid-January survey, the organization's EOC committee had just completed the 2005 annual management plan reviews of each of the EOC plans.

The committee had prepared one summary sheet on each management plan listing the indicator results for 2005, accomplishments, and the new 2006 indicators.

This handout was distributed to everyone participating in the EOC session as well as the surveyor. "Together as a group, we reviewed the information for each plan with him, and he asked clarifying questions about the material," says Leslie Phillips, accreditation coordinator. "The surveyor seemed pleased we had prepared the information. We felt it allowed for a more organized and controlled discussion of the material."

After the EOC management plan review and discussion, the physician surveyor was called in, and both surveyors provided a disaster response scenario. "He did look at our hazard vulnerability analysis but did not end up using a situation that we had identified in our 'Top 5,'" says Phillips.

The scenario given was a tornado that had hit nearby, with two schools and several restaurants affected. "He asked us to start by taking him to the location where our decontamination equipment was stored," says Phillips. "He talked through how it would be deployed, and we then walked down to the physical space where the decontamination tents would be set up."

The surveyors asked questions about how the flow of traffic around the decontamination area would be handled or re-routed, and how patients would be assessed, triaged, and registered and where they would receive care.

Next, they asked to see the incident command center and discussed more operational issues, such as how many days of water and food were on hand if the organization had to stand on its own.

"The surveyor emphasized the importance of assessing our abilities to operate independently for an extended period of time, referencing the Katrina and Rita disasters," says Phillip.

To prepare for the survey, mock patient tracers were conducted. "We conducted many, many tracers to help staff feel comfortable with the tracer methodology, answering questions from the surveyors and bragging on what they do well," says Chaloupka. "We also had staff from our system come to our facilities and conduct practice surveys."

A "My JCAHO Companion" pocket guide was given to all staff, with key points covered such as requirements for the National Patient Safety Goals. "The pocket guide was split into clinical staff information and all staff information," says Chaloupka.

The organization had a list of duties assigned to be done when the surveyors showed up. These included e-mailing staff, managers, directors, and system directors of the surveyor's arrival, and notifying the page operator to announce a welcome to our surveyors. "This welcome announcement was another way to notify staff, as well as notifying our patients and visitors the JCAHO was onsite," says Chaloupka.

The organization's accreditation coordinator began checking the JCAHO web site every morning about 6:30 a.m. EST to see if the surveyors were coming. "The day they came, she was able to get to the hospital before they arrived and had their room set up with all the notebooks on the tables for them," says Chaloupka. "The surveyors were so impressed by our preparedness and welcome that they thought we were tipped off concerning the survey date."

The surveyors liked the performance improvement (PI) posters, which were displayed on all units and in each department. "These posters demonstrated how we use data and the PI process to improve patient care," says Chaloupka.

[For more information, contact:

Paula Chaloupka, MSN, RN, Director of Care Coordination, Baylor All Saints Medical Center at Fort Worth, 1400 Eighth Avenue, Fort Worth, TX 76104. Telephone: (817) 926-2544. E-mail:

Leslie Phillips, Accreditation Coordinator, Baylor All Saints Medical Center at Fort Worth, 1400 Eighth Avenue, Fort Worth, TX 76104. Telephone: (817) 926-2544. E-mail:]