Joint Commission Update for Infection Control

Have materials at the ready for Joint survey

Be 'able to give them what they're asking for'

Demonstrating that you're prepared is important when Joint Commission surveyors knock on your door, says Susan Bukunt, RN, MPA, CPHQ, senior director of clinical quality and patient safety at El Camino Hospital with two campuses in Los Gatos and Mountain View, CA. "Being able to give them what they're asking for shows them that you're ready and you take this seriously," she says.

Prior to El Camino's most recent survey, Bukunt had readied all the documents on The Joint Commission's survey prep guide in binders. "We had our team on alert so that when we called, we mobilized everybody, and by the time of the opening conference I had all of my escorts ready. I had every binder that they could ask for in terms of committee minutes. Everything that was on that list we had into that room by 8:30 in the morning. And so that showed them that we were prepared and we were organized."

She also had a PowerPoint presentation ready for the opening meeting with the surveyors, who came seven months prior to their tentative "due date." "I've heard some surveyors do not let you [use presentations]. We decided to have it ready for those things and then just keep our data updated so that even if they said, 'We don't want a PowerPoint, we just want you to talk,' people would have discussion points in front of them." So if a surveyor said, 'tell me what you've been working on that you've had success or not so much success with,' "we had those examples there for people in the room to sort of rattle their brains to think about. And that made people feel more confident."

In preparation for the survey, Bukunt says there are 23 "surveyors" at the Mountain View campus and about 10 at the Los Gatos campus. Those are managers or directors within the organization who have been trained to do monthly surveys. They are outfitted with a checklist of about 75 items, and then the information is put on the hospital's dashboard. "So on the dashboard, if you miss one item it's red for the whole hospital. Everyone has to be perfect for it to be green. We post it on our internal web site and all the managers, they can drill down to their own unit level. They can drill down to a service line level or they can look at the entire hospital," she says.

When she surveys a unit, Bukunt takes the checklist with her and interviews staff while walking around the unit. She pulls a patient's record, a physician record, and a competency file. "And then before I leave the unit — and it usually takes about two hours to do a survey — we make a copy of it and I do a debrief with the manager of that unit and tell them what they missed and why they missed it," she says.

The surveyors arrived in March. Bukunt says that in California, the Institute for Medical Quality (IMQ) accompanies The Joint Commission on its survey and provides the physician surveyor. She says the surveyors were more collaborative, thorough, and educative — "a big difference in their approach from our survey three years ago."

"They put the staff at ease more so than I've seen them do before," she says.

They also were willing to look at clarification. "So if they had a question about something, it was 'Show me,' and I could produce a document. I could produce an audit. They were willing to look at that and take that into consideration."

Surveyors focused on patient safety and the National Patient Safety Goals, she says. The system received no direct findings, only five indirect ones.

"I think one of the things that the surveyors were very complimentary of was our quality program and our use of data. And they liked the fact that they could trace the data through committee minutes and see closure where things had been looked at, talked about, " she says.