Accreditation Field Report

Use priority focus report as 'road map' for survey

Kathleen Rauch, RN, BSN, director, Center for Clinical and Operational Performance Analysis, Risk Management & Infection Control at Princeton Healthcare System, felt pretty good coming out of a recent Joint Commission survey. Because she knew what to expect and what was needed to get ready.

Her takeaway from the experience: "We had certainly been hearing plenty that the focus was going to be more on that consultative basis versus just really looking to home in on compliance, and I think that we felt very much that there was a different experience when they came out."

Survey prep: Tools and suggestions

The first thing she says she would share with others in preparing for a Joint Commission survey is using the priority focus report for guidance. "They really do use that as a gauge. Certainly when we had our opening meeting, our orientation with the surveyors and leadership, our lead surveyor brought that to the table... He said certainly this is going to be a starting point for us to look at these areas to see how are you doing," she says.

She suggests looking at the report to identify areas for improvement. "At least for our experience, they absolutely used those reports as part of their road map for starting their tracer activity."

She says for hospitals accredited by The Joint Commission, the priority focus process summary report, which comes out quarterly, is available on their internal site. The report culls data from various sources, including the Centers for Medicare & Medicaid Services, any complaints filed against the hospital, pre-survey information taken from the hospital's application, past survey findings, information from The Joint Commission's quality monitoring system database of complaints and non-self-reported events, core measure data, and external data from sources such as MedPAR and HCAPS.

The report "gives you the top three or four priority focus areas such as communication, assessment, patient safety, staffing," she says. "It also then gives you some information as far as clinical service groups, where there's opportunity there. So for an acute care hospital, it could be general surgery/psychiatry/oncology/general medicine. Because they're trying to give you some insight based on this information they've put together where they're seeing possibilities that should be explored. And that's what it's meant to be. It's meant to be a tool."

Rauch also looked to The Joint Commission's survey guide, survey planning tools, and activity guide to help preparedness. One surveyor, she says, "articulated many times that [the activity guide] was exactly what he was going to be using for the systems tracers. When he facilitated the environment of care, emergency management, and competency tracers, the surveyor stayed true to his word and followed the system tracer criteria in the activity guide."

Rauch followed the survey activity guide to create binders with the appropriate documents and kept those regularly updated. "Most everything they needed was in the binder, which made the document review process easier for both the surveyor team and us," she says. "The binder contained our PPR measure of success dashboard, our organizational PI plan, as well as other documents, which also served as guides to their survey activities. I really felt that by having the right documents available upon the surveyor team arrival that things flowed much better for us in our discussions with them, and that when they were out surveying, they were really able to see what we had in that binder is really what we do in practice. I think that that was a real strength for us in this survey."

And the survey begins....

Rauch says the system had Joint Commission Resources (JCR) consultants visit last fall who had said some surveyors prefer PowerPoint presentations, while others don't. The PowerPoint presentation, used for the surveyors' orientation session, "wasn't too much. It wasn't too little. What it did was just gave them a quick snapshot of our organziation. It clarified for them what are our inpatient services, our outpatient services, and it wasn't heavy. We tried to keep it somewhat lean... It gave our leadership team prompts of the things we thought were important, that we wanted them to know. And it helped us to open up some dialogue."

The presentation also included organizational PI priorities and what the system was doing for quality and safety. Rauch also had prepared a presentation for the data system tracer based on JCR's suggestions, but the surveyor preferred an open-table discussion.

"My recommendation to folks who are getting ready for systems tracers: Make sure you have people who can really have that conversation at the table, rather than one person owning the conversation." She says the institution had been rehearsing system tracers, which she says prepared staff and helped them work off each other and know what input each could make individually. "One of the surveyors said when we did our medication management tracer, he was really impressed between how pharmacy was able to really be engaged and how nursing could speak to certain components and it really didn't just sit with one person or one practice," she says.

Rehearsals also were done with leadership and physicians. She says The Joint Commission likes to see physicians in the leadership session to see their engagement in the organization's goals. Beyond physicians, the CEO, a member of the board, the president of the medical staff, and the vice president sat in on the meeting.

"It was really significant to the surveyors that we had a board member who came and sat and who was able to articulate what is happening in our organization, what we're doing for quality and safety. He could speak to sentinel events and quality data. It really sent the message that we have good communication and that there is engagement on all levels," she says. "There wasn't one person who sat at the table who didn't contribute something, and it was because we had done the practices."

For the leadership session, Rauch pulled together information on the culture of safety, disruptive behavior, conflict management, and sentinel events. One recommendation she had received was that it wasn't value-added to just have a room full of people. "Have folks who can really work with each other and demonstrate that it's very collaborative."

For infection control, she says the surveyor offered a choice — either to sit down with the entire infection control committee or to meet with just the infection control coordinator and epidemiologist and then to move on to do the tracer. "We opted for the latter because that's really what he said they're looking to move toward. They're looking to move away from the group infection control systems tracer. He looked through our planning and our risk assessments, and that was the bulk of his evaluation."

She says surveyors want to know the reasons behind the way you do things. "They want to hear that you're not just arbitrarily doing or not doing things, that there's actually thoughtfulness, that you sit down and look at it and say, 'Well, this does have risk, but when I look at the benefits I have to say I think that it's still the better thing to do.' That wasn't certainly something we heard last time," she says.

She says, in some ways, The Joint Commission has become more similar to DNV. "They're trying to really get us to think more about evaluation, analysis, really using data, not just sitting on data. Because that was a big focus, too. 'So tell me how did you come to that conclusion? Tell me how you used data.' That was really very commonly asked during any of the tracers," she says.

Surveyor focus

Rauch says surveyors looked at dating, timing, and signing of H&Ps, as well as legibility and timeliness. "They asked almost every person that I can think of when I was with the lead surveyor about handoff communication." The system uses the SBAR (Situation-Background-Assessment-Recommendation) technique, even though Rauch says The Joint Commission wants you to have a format but doesn't specify which one.

Surveyors also looked at patient identification — "what are your identifiers and when would you do it?" They looked at the med rec process, though it is not yet being scored.

They evaluated the patient assessment process, specifically skin, by asking staff if they use the Braden score and how frequently it's used. They looked at pain — pain assessment — and nutrition, as well as the system's policy for falls.

When surveyors were walking around, they also looked for expired equipment or materials and medication storage. Environment of care issues, such as documentation for dampers and having a call bell in the visitor bathroom adjacent to the emergency department, were discussed.

Asked if surveyors focused on the National Patient Safety Goals, Rauch says, "No. I didn't find that. I found that the priority focus report was really the roadmap for them. At least for those first couple days. That they really were looking to see what those topics were, how were we doing with those?

"I think that we were able to pretty consistently demonstrate to them that we don't just wake up in the morning and say, 'Oh, this sounds like a good thing' and just throw it up in the air. That we really sit down and look at things to determine what we should be doing and how we should be doing it," she says.