You must be involved in survey preparation

Volunteer to be a leader

When Lauree M. Miller, director of patient access at Catholic Health Initiatives — Nebraska in Lincoln, became the organization's coordinator of admissions, patient access didn't have anyone represented on the hospital's committee that oversees accreditation by The Joint Commission.

The hospital was looking for someone to lead the patient rights and responsibilities chapter, so she volunteered. Patient access leaders have to "raise their hand and be involved" in Joint Commission initiatives, advises Miller.

"It's important for us to see the bigger picture, not in just patient access, but throughout the patient's visit," she says. "It's also a growth opportunity to get involved in the organization."

It might be helpful for the Joint Commission committee to have a non-clinical person at the table, adds Miller. "If you don't want to do it alone, you can tag-team with a clinical person to lead the chapter," she says.

Cheryl L. Webster, director of patient registration services at Beaumont Hospital in Royal Oak, MI, participates in her hospital's Joint Commission teams alongside clinical staff. "I can help keep our team supportive of their efforts and standards as well," she says. "Our functions overlap, so it is important to work together."

Here are two ways to help your organization comply with Joint Commission standards:

• Be involved in mock tracer activities.

How the tracers are conducted will drive what kind of questions registration staff members might be asked, explains John Wallin, RN, associate director of standards interpretation at The Joint Commission.

"It may have nothing to do with privacy of information," he says. "I've been out on a survey and asked staff, 'How do you, as a registration clerk, identify an infectious patient and transport them to a safe area?' Additionally, other infection prevention and control questions may be asked."

• Perform a risk assessment of the admission process.

"Conducting a risk assessment is one of several tools an organization may use to review their policies and procedures for the admission process," advises Cynthia Leslie, RN, associate director of The Joint Commission's Standards Interpretation Group.

Leslie says this assessment is an opportunity to look closely at these areas: What is our process? What admission questions are we are asking? How do we ensure privacy? Are registrars educated as to policies and procedures? Has their competency been assessed?

Patient access team leaders and supervisors at Palmetto Health Richland in Columbia, SC, visit registration areas to role play as Joint Commission surveyors. "We know that they know the information, but we want to be sure they are comfortable answering the questions," says Melissa R. Almond, patient access team leader. "We want to be just as prepared as the clinical staff."

At Beaumont Hospital, Webster asks supervisors from other areas to role play as surveyors, and she reminds registrars that surveyors will ask them questions about things they do every day.

"Some staff know what they are doing, but are a little shy about being put on the spot with a stranger asking questions," she says. "We just want them to shine as they talk about how they perform their tasks."