Accreditation Field Report: Surveyors impressed with medical staff involvement

Continuous preparedness pays off

When the Joint Commission’s new survey process was announced in 2003, quality managers at Hilton Head (SC) Regional Medical Center were challenged by hospital leadership to take a proactive role and volunteer as a test site for the unannounced survey process to take place in 2004.

"It was a very new process, and there wasn’t a lot of literature out there at that point," says Lori Ross, RN, BS, MBA, vice president of clinical quality improvement.

"We had to be prepared for them to come anytime as of Jan. 1, 2004," she adds.

Quality managers worked hard to get all clinical staff and physicians informed about the new patient tracer methodology and how it would affect their role during the survey, using daily e-mails, newsletter articles, crossword puzzles, bulletin boards, staff meetings, mock surveys, role playing, and "pocket pals" listing the National Patient Safety Goals.

"We really worked on educating them about the standards and made it real for them," says Sharon Morris, RN, BSN, MSHA, director of education and JCAHO coordinator.

If any problems were identified during mock survey sessions, quality managers would follow up immediately with an action list.

"For instance, we had a situation with medical staff using unapproved abbreviations, so we made sure we highlighted that at general medical staff meetings and used our medical leadership to get that message through," Ross notes.

But after months of continuous preparation, staff motivation was waning. A sign in the lobby read, "We welcome JCAHO to our culture of excellence."

"That sign stayed in our lobby for more than a year," Morris says. "We noticed that the interest level with staff was getting a little tired — after all, we had gone through a whole year of this. They needed re-energizing."

So quality, education, and human resources (HR) got together to address morale issues by putting together reward packets for staff, with gift certificates, lunches, and candies. "Staff were rewarded for simply participating in the mock survey process," she explains.

"So if we asked them a question, regardless of whether the answer was correct or not, we still rewarded them. The point was to get them involved so they would feel prepared for the real survey and to encourage participation," Morris says.

When JCAHO surveyors finally arrived in December 2004, the continuous preparedness paid off. "JCAHO said the things that the education department put together were fantastic," she notes. Surveyors went to great lengths to make sure staff were not intimidated and were comfortable, Morris adds. "But anything you talked about in your scheduled sessions, they would look for during tracers. It was incredibly thorough — if you said you were doing something, you better have been doing it."

Here are key points of the survey:

Surveyors wanted to see an interdisciplinary approach to planning patient care.

"The surveyor actually participated in one of our interdisciplinary team meetings," Morris says. All members of the team were represented and addressed pertinent questions regarding the delivery of care, including pain management, referrals to the dietitian, medication management, patient safety, and clinical practice guidelines.

"The JCAHO surveyor really liked that we had our physician advisor co-chair in this meeting along with our care management director," she adds.

The surveyors also were impressed with a "communication sticker" that is placed in the medical record for each patient discussed, which includes a space for the appropriate discipline to check when referrals are generated through the meeting process.

Surveyors wanted to see evidence of compliance with educational requirements.

The HR director had audits in place to ensure competencies and document compliance for all employees. This was done by requiring a documents audit for new employees at 90 days — including department orientation checklist and competencies, ongoing department notification of required training, ongoing audits of HR files for document compliance, and one-on-one meetings with department directors to review compliance with the organization’s education and competency program.

Involvement of medical staff impressed surveyors.

The medical staff, including the chief of staff, medical director, physician chairman of the board, and other physicians participated in both individual tracers and scheduled sessions. "They asked questions and were prepared to address issues with the surveyors. This showed that they were actively involved, interested, and engaged in our performance improvement efforts. This got the survey off on the right foot and suggested to surveyors that there is a culture of quality," Ross says.

Strong medical staff leadership was key during survey preparation, with education provided to the medical staff on all JCAHO requirements and special emphasis on the patient safety and leadership standards. "We worked hard to keep the medical staff involved in the entire process," she explains. "We educated the physicians via newsletter articles, memoranda, and face to face during committee meetings."

The organization’s main challenge now is to keep the momentum going. "We are going to continue with mock surveys for the 2005 standards," Morris adds. "Sometimes, it’s more difficult to sustain improvement than to get to a certain point, and we just want to keep the process going."

[For more information, contact:

Sharon Morris, RN, BSN, MSHA, Director of Education, Hilton Head Regional Medical Center, 25 Hospital Center Blvd., Hilton Head, SC 29926. Phone: (843) 689-8448. E-mail:

Lori Ross, RN, BS, MBA, Vice President, Clinical Quality Improvement, Hilton Head Regional Medical Center, 25 Hospital Center Blvd., Hilton Head, SC 29926. Phone: (843) 689-8286. E-mail:]