Accreditation Field Report

Surveyors impressed with best practice strategies

Exchanging ideas with surveyed hospitals pays off

Sharing best practices with other organizations was a key factor that enabled Winthrop-University Hospital in Mineola, NY, to excel in its recent Joint Commission on Accreditation of Healthcare Organizations survey.

"I don’t think there were any surprises during the survey — and we attribute that in large part to having very strong communication with other hospitals that were recently surveyed," notes Barbara Kohart Kleine, vice president of administration and Winthrop’s JCAHO coordinator.

Quality professionals at Winthrop collaborated with their peers through the Rensselaer, NY-based Healthcare Association of New York State, the New York City-based Greater New York Hospital Association, and their colleagues in the New York Presbyterian Healthcare System.

"We were bombarded with so much information about other hospitals’ processes and survey experiences, and we borrowed from their best practices," says Kohart Kleine.

Surveyors took a collaborative approach when talking to staff, says Kohart Kleine. "No one was fearful of giving a wrong answer, and they really enjoyed themselves," she adds. "It was a conversation and a dialogue."

The management team members acted mainly as observers, in a marked departure from previous surveys, says Eileen Magri, the hospital’s director of nursing for maternal and child health.

"When the surveyors came onto a unit, they would say to a staff member, Tell me about your patient,’" she says. "That was the perfect opportunity for staff to talk about patient care with a clinical focus — the questions didn’t need to be pulled out of them."

Surveyors focused on the care the patient was receiving, Magri says. "As a result, it really was a much more collaborative discussion that the staff had with the surveyors."

There was less "JCAHO-speak" and more of an interest in whether staff really understood the principles behind the National Patient Safety Goals, says Kohart Kleine. "They were very accommodating in that regard," she says. "If you didn’t use the exact terminology, that didn’t matter to them. They were interested in whether patients were being given safe care."

Here are key survey practices that impressed surveyors:

Poster boards were created that listed every inpatient and outpatient area with the clinical service represented.

These boards were located in the conference room where the surveyors met each morning and afternoon and ate lunch, and provided easy access to this information.

"The surveyors were able to see at a glance what our patient population was — they knew by looking at these grids what to expect on each patient care unit," Kohart Kleine continues. "They were prepared for the types of patients and didn’t have any surprises when they arrived on the units. It took stress off them and consequently took the stress off the staff as well."

Surveyors met with Kohart Kleine twice a day. "We would sit down and look at this giant grid with big boxes for them to check off, and we were able to coordinate services and product lines that flowed together," she says. "It was a very collaborative process."

The poster board idea was shared by colleagues at Nyack (NY) Hospital and showed the surveyors that the organization really knew its priority focus areas, says Susan Robertson, assistant vice president for quality improvement.

"We found it to be a brilliant strategy," she says. "It really shows the surveyors that you have put some forethought into their visit and are trying to make it as easy as possible for them to do their work. The more you can take that planning out of their day, the more autonomy the hospital has with the survey process."

Invite surveyors to a medical staff luncheon.

Kohart Kleine asked the physician surveyor if he would like to attend a medical staff leadership luncheon and got an enthusiastic response.

"He came in and did a PowerPoint presentation for 80% of the executive committee of the medical staff, the chairman of board, and the president of the hospital, which reinforced leadership communication," she says. "I would recommend that any hospital take the time and do this, because it shows that your medical staff really takes an interest in their consultations."

Ensuring that key members of the medical staff are present during the survey is a challenge, since visits to patient care areas no longer are scheduled in advance. To address this, Kohart Kleine put departments on "red alert" on the first day of the survey, updating them continually during the next five days as to when they should expect a visit.

"The chairpersons and chiefs would tell me which were particularly good or bad times," she says. "So I was able to say to the surveyor, I know you really want to go to OB or pediatrics, and our chairman would really like to participate.’ Our medical staff never felt like they were being pulled at the last minute, and they and the surveyors made accommodations."

The organization took advantage of its three scheduled systems tracers for data, medication management, and infection control as an opportunity to get several physicians to be present and speak to surveyors directly. "For example, I was able to get our chief of cardiology to present our core measure results during the data tracer," says Robertson. "Our physicians greatly enjoyed having that forum as well."

Give physicians a tool to improve legibility.

The organization’s medical staff executive committee has taken a very aggressive stance on the issue of legibility and recently amended its rules and regulations to reflect the requirement for legible medical record entries, reports Kohart Kleine. As part of this campaign, any member of the medical staff who attended a patient safety update conference was given a special self-inking pen that stamps his or her name, credential, and phone number. "This makes it easier for staff to follow up with them if they have questions about a progress note or order," says Kohart Kleine.

Surveyors were impressed when reading through the medical staff executive committee minutes and learning they had taken a leadership role to address legibility, she says.

"No doubt about it, there were some illegible entries up on the units. But when they asked nursing staff what they do about it, they consistently said that if an order can’t be read, nothing is done until it’s clarified," Kohart Kline notes.

In addition, nurses told surveyors that they could call the order’s author because he or she was identified with the pen’s stamp, she adds. "The surveyors really felt that was a very positive approach to ensure legibility."

[For more information, contact:

Barbara Kohart Kleine, Vice President, Administration, Winthrop-University Hospital, 286 Old Country Road, 2nd Floor, Mineola, NY 11501. Phone: (516) 663-2204. E-mail:

Eileen Magri, Director, Nursing, Maternal and Child Health, Winthrop-University Hospital, 286 Old Country Road, 2nd Floor, Mineola, NY 11501. E-mail:

Susan Robertson, Assistant Vice President, Quality Improvement, Winthrop-University Hospital, 286 Old Country Road, 2nd Floor, Mineola, NY 11501. E-mail:]