Take time to prepare, include others in survey preparation

Don’t cram for survey; make meaningful changes

As the triennial Joint Commission on Accreditation of Healthcare Organizations survey continued for three days at Olympic Memorial Hospital in Port Angeles, WA, Maureen Guzman, RN, director of quality and strategic value at the hospital, realized that the two years of preparation was paying off.

She now suggests that is one of the biggest lessons from Olympic Memorial: You can’t cram for a survey and expect to actually improve quality at your facility. Meaningful changes often take time, and Olympic Memorial took two years to achieve some of the changes that landed them a perfect 100.

"It’s like studying for a test in college," she says. "If you cram at the last minute, you might get the questions right until the professor asks you something slightly different, something that digs deeper into what you really know. Then you’re lost."

These are some other lessons from Olympic Memorial:

  • Be willing and prepared to showcase your strengths.

The survey process can be nerve-wracking, so some providers just grit their teeth and wait for it to be over. Big mistake, Guzman says.

"If you’ve done something really good in a department, talk about it — show it to the surveyors," she says. "That’s OK, more than OK. The surveyors want to see what you’re doing right, even if they don’t know to ask you about it. It’s good to show your enthusiasm."

  • There is strength in numbers.

Having a large circle of hospital leaders and staff directly involved in the survey process broadens the pool of knowledge available to the surveyors. The surveyors may not ask for input from everyone who is available, but their presence shows support from a wide range of experts. And in some cases, the assembled brains might rescue a struggling staffer.

"We had one instance in which the nurse surveyor couldn’t find the order for the last time a patient had been in restraints," Guzman says. "But we had some knowledgeable people hovering who explained that the patient had expired recently and so there was more time allowed to get the record together."

  • Do whatever is required to get your medical staff and board of commissioners on the team.

Guzman says the surveyors were pleased with the way the physicians and board members participated fully in the survey process and obviously had been instrumental in the quality improvement process. Showing that kind of involvement, rather than having them marginally and begrudgingly involved, makes a big difference to the surveyors.

That may not be easy, but you must strive to show consensus, that you’re all part of the same team.

"We asked the CEO to help us determine who would be good representatives from the board," Guzman says. "Then we set up individual meetings to get them on board. Some of them were not fond of the Joint Commission, so it took a lot of talking."

When it came time to educate the board members about the survey process, Guzman was careful to avoid lecturing or any presentation that sounded like a PhD dissertation.

"It was more like just talking about how these surveys work, getting them to a real comfort level by the time they would actually talk to a surveyor," she says. "We spent about 12 hours with the board members doing that."

For the medical staff, Guzman and others asked to be put on the agenda for physicians’ meetings. They spent about 9 hours educating the physicians about the survey process, with the same emphasis on not lecturing and making everyone comfortable with terminology and goals.

  • Consider your policies and procedures to be "living documents."

It’s easy to think of policies and procedures as something you get in shape for the Joint Commission survey and then forget for a while. But Guzman says you must think of them as living documents that must be updated and improved whenever necessary. That change in attitude will result in more meaningful documents that improve quality of care and show substantive improvement to Joint Commission surveyors.

  • Never utter the phrase: "Because the Joint Commission says so."

Strike that phrase from your vocabulary and replace it with: "Because it’s the right thing to do."

  • Focus on how you can improve your organization, not how you can prepare for the survey or respond to the last one.

That’s more than just an ideal way to look at things. It actually pays off in the long run, Guzman says, because you improve the organization in more significant ways. Joint Commission surveyors will see the difference.

"They’re going to look at how you judge yourself, how much you hold yourself to high standards, rather than just how much you can follow instructions written in the standards," she says. "Waiting for the survey to show you what’s wrong so you can fix it is not the best way. Surveyors won’t be impressed by that attitude."

JCAHO surveyors’ questions show areas of focus

These are some of the questions posed to staff at Olympic Memorial Hospital in Port Angeles, WA, by Joint Commission on Accreditation of Healthcare Organizations surveyors during its recent survey:

  • How do medical staff react when told you don’t have enough staff to take care of a patient? How do charge nurses react?
  • What kind of patients are admitted to the critical care unit?
  • What arrangements ensure there is adequate medical staff coverage for the critical care unit?
  • What determines which caregiver will take care of which patient?
  • When using the Pyxis dispensing system, how do you monitor the medications?
  • How do you make sure that surgeons don’t bring in unapproved equipment from vendors?
  • Do personnel from all shifts participate in fire drills? How do you make sure?
  • Are you working to reduce mercury contamination?
  • How would you respond if your water supply was contaminated?
  • How do you monitor sharps injuries?
  • How are you addressing the hazards posed by medication abbreviations?
  • Since you imposed a moratorium on vaginal birth after cesareans, how do you handle those patients?
  • If you have no patients in the obstetrics unit, what do you do with the staff assigned there?
  • Do you document patient education? How?
  • What determines a "short stay" in your hospital? How do you decide whether a patient is a short stay or full admit?
  • Do you use preprinted medication orders? In what units?
  • How do you provide effective pain management? How have you improved your pain management program?
  • What process do you have in place for emergency physicians to access patient records?
  • When have you conducted a hazard vulnerability analysis? What did you learn? How did you respond?
  • When and how did you get consent for this patient’s surgery? Has the anesthesiologist seen him?