Rely on presentation when it's time for accreditation
Rely on presentation when it’s time for accreditation
Use run charts, storyboards to show improvement
Any chef will tell you that good food can suffer from bad presentation.
Even though you’ve worked hard on your agency’s compliance with Joint Commission on Accreditation of Healthcare Organizations standards for months, effectively presenting your results to surveyors is the final piece of the accreditation process.
But you don’t have to be a computer whiz who creates flashy visual aids to prove to the Joint Commission you’re in compliance with the performance improvement standards.
A ruler and a piece of poster board will suffice if you’ve got solid numbers to plot that tell your agency’s story of quality improvement processes and methods followed.
You don’t want to sit back and hope the surveyor can determine your level of compliance solely by sifting through reams of records.
"I’ve got only 45 minutes to show her what I’ve been doing for the last three years," says Kay McRae, RN, continuous quality improvement coordinator for Memorial HomeCare in Lufkin, TX. "They don’t want to pore through all that. They want quick and easy."
McRae offers these tips for showing the Joint Commission surveyor what you’re made of:
• Pick two or three of your best CQI projects.
Even if you did 10 or 12 throughout the year, narrow it down to the ones with the best outcomes, where you followed your methodology, and where you can show that your "action" resulted in the change, suggests McRae. "Numbers sometimes just go up related to nothing you’re doing. That’s not a good storyboard candidate," she says.
The project she picked for her storyboard was the Nutrition Screen and Referral to Registered Dietitian (RD) project, in which the agency identified problems with RDs participating in team conferences, consulting with RN team leaders, and scheduling home visits. The storyboard walks the surveyor through situation analysis, data collection, data analysis, goals, and actions, which result in the agency deciding it has enough patients needing nutritional consultation to warrant hiring a part-time RD to alleviate the problems. (See sample storyboard panel, above.)
"The storyboard needs to tell the story by itself," McRae says. She created her storyboard by pasting panels containing descriptions of the project’s steps onto a sheet of posterboard.
She chose the Care Plans project as one best illustrated with a run chart. (See sample run chart, p. 157.) In the care plan’s CQI project, the agency tracked the compliance rate for two indicators from March 1996 to December 1996. Indicator 1, "Evidence indicates that patient’s goals as stated on plan of care are evaluated at the predetermined review date," began March with a compliance rate of 56%. Indicator 2, "Evidence indicates that patient’s response to interventions listed in care plan is documented," started with a compliance rate of 35%.
McRae plotted on a run chart each month’s compliance rate until compliance for both indicators reached 96% in December. She verbally explained to the surveyor each of the actions the agency took to improve these rates, and showed how those actions affected each compliance rate for the month.
• Don’t just look for a line that goes up.
"They don’t just want to see a little run chart that shows you improved something. They want to see how you improved it," she says. Consider verbally explaining the methods you used. Or you can use a storyboard to accompany the run chart and explain your actions along the way.
• Don’t shy away from a good opportunity just because you’re not at 95% yet.
Some agencies "are afraid they will tattle on themselves; they’re afraid they will be cited because they are not at 100%," says McRae. But this mentality will cause you to overlook good performance improvement projects. If your method was good, your team had good ideas, and you perhaps even did a fishbone cause-and-effect diagram, don’t discount the project just because the numbers don’t yet look as good as you’d hoped, McRae says.
"Tell them, We’re still working on it,’ and ask them if they have any suggestions, because you’re paying them good money to get their help on your problems," she says.
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