Joint Commission survey prep made fun for staff

Games, prizes help reinforce teaching of standards

It is not unusual to form committees to help staff prepare for a survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Lake Region Healthcare Corp. in Fergus Falls, MN, put in place workgroups for each chapter on the JCAHO standards a year and a half before its survey to ensure that the medical center was in compliance. In addition, the chapter chairs decided to form a JCAHO Fun Committee to brainstorm fun and unique methods to educate staff.

"We wanted to create a fun learning environment for our employees. We have found from past experiences that implementing fun into adult learning creates more compliant employees who receive, process, and understand the information in an accepting manner," says Brandi Sillerud, RN, education coordinator at Lake Region Healthcare and a member of the Fun Committee.

The committee came up with two ideas that would make learning fun but also reach as many staff as possible. The first was a colorful display board near the employee cafeteria with cutouts and phrases that staff could look at as they were walking by even if they were in a hurry. The display focused on one chapter of JCAHO standards at a time, highlighting the changes that had been made in that chapter.

The phrases for patient and family education included:

  • every patient should be taught about his or her diagnosis;
  • every patient should be taught about pain management;
  • every patient should be taught about any new medication started.

Staff could pick up a crossword puzzle on JCAHO standards from a table next to the cafeteria. There also was a box on the table for the completed puzzles.

The web site was used to create the puzzles that consisted of 10-16 questions about the chapter covered on the display board. Some of the questions were about hospital policies. "We wanted them to look into the policy books if they had questions so they would know where to find the answer," says Sillerud. She knows that at least some of the employees were pulling the policies and looking up answers because she received a call from a nurse one day asking for the answer to four/across on the puzzle. "We have looked in every policy book and we cannot find the answer," she told Sillerud.

Before changing the topic on the display board, members of the Fun Committee drew 10-15 puzzles from the box and awarded small prizes for participation. They included certificates for meals, desserts, or drinks in the cafeteria, which the committee had purchased. The committee’s average return on the puzzles was 33% to 50%.

Face-to-face encounters

The second activity implemented by the Fun Committee to educate staff was a mock survey. Committee members took turns visiting different departments to ask staff survey questions. When visiting a unit, they took a cart that had a basket filled with questions from the various JCAHO chapters from which employees would draw. They also had baskets of candy to reward those employees who participated. All participants also were signed up for a drawing for such prizes as gift certificates, shirts, and blankets.

The questions focused on new information in the chapters or most frequently asked questions by surveyors. To determine which questions surveyors might ask, the committee gathered several reference books published by the Joint Commission.

During the mock survey, employees were given cheat sheets to place behind their name badges that contained several commonly asked JCAHO questions, such as the name of the patient safety officer at the health care facility.

The questions in the basket were no surprise to staff because each floor had been given a copy of the questions and answers before the mock survey took place. One-page flyers on all the information pertaining to the display boards and crossword puzzles also were posted in advance. "We just took the standards and wrote them in the form of a question. When we did the crossword puzzle we reworded it," says Sillerud.

Questions from the patient and family education chapter included the following:

  • How are patients educated about pain and managing pain as part of their treatment and where is pain management education documented? [All patients are taught about pain on admission via a pain management handout, with pain scale, pain management posters in all rooms and verbal explanation by the caregivers. We document on the interdisciplinary education record.]
  • Who participates in the planning and providing of education to patients and families? [All patient care providers — it is an interdisciplinary process.]
  • How do you determine the learning needs of patients and families? [By asking questions.]
  • What variables do you consider when assessing a patient’s needs, abilities, and readiness for education? [Variables such as cultural, religion, emotional, motivation, physical and cognitive limitations, language, and cost are considered.]
  • When do you provide education to patients or family members? [At the first communication.]
  • Where do we document patient education? [On our interdisciplinary patient education record.]
  • What grade level are patient education materials written? [Sixth-grade.]

While there is a big push to make sure staff know the standards before a survey, they are covered on a regular basis whether a Joint Commission survey is scheduled or not. When a new standard is implemented, such as managing pain, an educational blitz on the topic takes place. To teach staff about pain management, Sillerud distributed handouts, put up posters, and attended unit meetings to discuss the new standards.

"When a new standard is implemented, we send out a newsletter. We did one specifically on pain and how to teach patients about pain management and making sure they understand how to use a pain measurement scale," says Sillerud.

Reinforcing the teaching about JCAHO standards with fun activities such as the display boards and crossword puzzles was very helpful. "We invested very minimal amounts of money but staff appreciate getting things in return for their time or seeing others win small prizes. I believe that by incorporating fun into learning staff are more willing to participate because it goes faster and they actually learn," says Sillerud.

[Editor’s note: If you have implemented a new or innovative program and/or created unique ways of teaching staff and patients in the area of patient education, let us know. We always are looking for ideas to share with the readers of Patient Education Management. Contact Susan Cort Johnson, Editor, Patient Education Management, (530) 256-2749 or]


For more information about the JCAHO Fun Committee and its educational methods on Joint Commission standards, contact:

  • Brandi Sillerud, RN, Education Coordinator, Lake Region Healthcare Corporation, 712 Cascade St. South, Fergus Falls, MN 56537. Telephone: (218) 736-8364. E-mail: