ED Accreditation Update: JCAHO preparation in a fast-paced ED
ED Accreditation Update
JCAHO preparation in a fast-paced ED
By Eileen Whalen, MHA, RN
Vice President
Trauma, Emergency and Perioperative Services
Elizabeth Criss, RN, MEd, CEN
Clinical Nurse Educator
Emergency Services
University Medical Center
Tucson, AZ
Probably one of the most difficult tasks facing an ED manager is preparing a fast-moving staff for a review by the Joint Commission on Accreditation of Healthcare Organizations. Most ED staffs thrive in an ever-changing environment and focus attention on what matters most in the next 30 minutes, certainly not the next 30, 60, or 90 days. So what’s a manager to do?
Educational theory says adults learn better if they can see what’s in it for them. It’s safe to say that conceptually they understand the necessity of the hospital successfully completing a Joint Commission survey, but perhaps not it’s direct impact on the ED.
Consider some posters around the department, in discrete places, that provides them with specific information on how important it is to have a successful Joint Commission visit. By including information in these posters regarding financial impact, loss of other sources of revenue, and the professional stigma of losing accreditation, the bedside nurse and support staff see what’s in it for them.
At University Medical Center (UMC), we use a more direct communication system through e-mail, staff meeting bulletins, and monthly fliers to facilitate getting this information to the staff.
If they understand the direct relationship between Joint Commission results and many of the services the hospital provides, they are more likely to take the process a bit more seriously.
Provide them with the information they will need to be successful during a survey.
The surveyors want the staff to have immediate recall of some topics, such as the fact that RACE stands for rescue, alert, confine, extinguish or evacuate, and verbal orders must be written down and read back.
However, they don’t expect that staff RNs will be able to discuss indicators of staffing effectiveness or the proactive risk reduction analysis process used at the hospital. Providing a pocket survival book, which they can refer to at any time to provide information on some of the less common items, can prove to be a useful adjunct.
At UMC we call this book JCAHO for Dummies, and it contains a brief discussion of our mission, vision, and values; the hospital’s strategic plan and priorities; quality improvement; incident reporting; patient rights and ethics; medication management; staffing effectiveness; competency; health information management; environment of care; and infection control; as well as helpful survey hints. The booklet was written by the ED director, clinical leaders, and clinical educator, formatted by the department secretary, and produced by our in-house printing service.
How about someone roving around at random times with various questions for the staff? Our staff members are asked to pick a card from a deck, and when they answer the question correctly, they are rewarded with cafeteria treats or candy bars.
Those who make incorrect responses are provided with a written copy of the answer; a concerted effort is made to revisit that individual within the next few days as reinforcement. Use someone the staff have a positive relationship with to conduct the roving Q&A sessions. Using this person will facilitate a positive experience for everyone involved. The ED management team members were the roving "riddlers."
Using some of these tips can help prepare the staff for some specific items, but the most eye-opening educational experience may be learning about the tracer process. Have clinical leaders take a different staff member on tracer rounds each day and maybe attend one or two of the leadership Joint Commission preparation meetings.
At UMC, staff members are encouraged to participate in any of the preparation activities within the institution and are frequently taken on tracer rounds as a way to provide insight into what the surveyors will look for. Staff were assigned specific accountability for environmental rounds to ensure compliance and ownership. Once the staff members have gotten a handle on the process, have them conduct a tracer survey on one of their own charts.
Getting senior leadership involved
At UMC, we developed a very organized approach involving senior leadership. Members of the leadership team conducted weekly tracers in every part of the hospital. Questions were developed and changed weekly. Staff responses to these questions were tabulated weekly, and educational sessions were developed specific to the area needing additional help. This process was fun for staff and leadership and was a terrific learning experience that stays with everyone long after your survey is done. The message became very clear that this is an organizational priority.
When we have asked nurses and support staff about Joint Commission preparation, the general response has been that this is a necessary evil, and they display no sense of ownership of the process. Including them in the tracer process and review of one of their own charts goes a long way in helping them understand what is going to be required during an actual survey.
Certainly there always are staff members who will put up walls to participation in the readiness process.
As nice as it would be to have an answer for this type of person, there is little that can be done if someone is not going to accept the information. Threats or reprimands could backfire certainly and result in the initiation of a very negative information campaign, which is something that needs to be avoided.
At UMC, we have adopted the philosophy that we must be in a state of constant preparation, so our educational preparation needs to be fun and change frequently to keep the staff involved.
Something else to consider is how the staff respond under the unexpected pressure created when approached by a reviewer. You may need to provide some group and one-on-one sessions to help them get comfortable with this new role they will have in the survey. It seems unusual that ED personnel would ever be at a loss for words, but frequently, in these situations, they freeze.
Reduce staff’s anxiety
Our use of leaders from other areas of the hospital conducting tracers in the ED helped staff overcome some of this anxiety. These are people that are not as well known to staff and can assist in demystifying the process while helping to build confidence with correct answers. Repeating this process on a very routine basis reduces the stress and drives home the information in the same format a reviewer will utilize.
Combining general information sessions, handy take-along booklets that contain some of the more obscure details, personal tracers, and mock interviews will give the staff a wide variety of tools.
Each individual on your staff learns and retains information in a different way, so look at providing them with as many different opportunities as possible to gain confidence and practice. Putting some effort into the development of some unique educational tools will certainly pay off in the end.
(Editor’s note: For more information on preparing for an accreditation survey, contact Elizabeth Criss at [email protected].)
Probably one of the most difficult tasks facing an ED manager is preparing a fast-moving staff for a review by the Joint Commission on Accreditation of Healthcare Organizations. Most ED staffs thrive in an ever-changing environment and focus attention on what matters most in the next 30 minutes, certainly not the next 30, 60, or 90 days. So whats a manager to do?Subscribe Now for Access
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