ED Accreditation Update

Preparation pays off for emergency department

In anticipation of unannounced survey visits by The Joint Commission, the ED at St. Jude's Medical Center in Fullerton, CA, created a "Code JUDE," or Joint Commission Unannounced Disruption Event, drill to help it prepare.

"This code would be paged to all managers, directors, and administrators, and everyone knew exactly what to do," explains Vicki Sweet, RN, director of emergency services.

A checklist was created for the drills, which was discussed during every shift. This checklist, which has evolved over time, includes items such as medications, crash carts, emergency drug boxes, patient rooms, confidentiality of information, documentation, open chart review, and infection control. (See a sample of the checklist.)

"We want staff members to do it the drills to increases their level of awareness," Sweet explains.

As it turns out, the ED was planning a drill on the day of their actual survey. The plan includes "stall tactics," during which the visitors are stopped by security and asked for identification. "Security then calls the administrative resources nurse. She then notifies our quality management department and a global page goes out to all managers," says Sweet. "As soon I got the page, I called our coordinator and said, 'The Joint Commission is coming; get out your lists and get busy."

For the most part, the visit went well because staff had been prepared, Sweet says. She admits that making sure your staff are prepared for those unannounced surveys is not easy.

"You have to treat each day as if The Joint Commission can walk in, and that's easier said than done; it requires a real difficult culture change," she says. "But the more transparent you make the process to your staff, the better off you will be."