Unannounced surveys keep staff on their toes

Steps to take for a constant state of readiness

One day you may show up to work and find that surveyors from The Joint Commission are in the process of surveying your facility. Because there is no preset date for surveys or advance warning, health care institutions must remain in a constant state of readiness.

The unannounced survey format currently used by The Joint Commission is good because it drives quality and patient safety, says Kathy Ordelt, RN-CPN, CRRN, patient and family education coordinator at Children's Healthcare of Atlanta. However, it is a lot more work for staff on a continuous basis.

"We need to be on our toes continually, looking at things through the eyes of the patient to see what we need to do to make sure the patient has a safe and quality medical encounter. Patient education is a big part of that," says Ordelt.

In addition to unannounced surveys, The Joint Commission now evaluates whether an institution complies with certain standards by following a patient through his or her care process, from hospital admission to outpatient care. Because the surveyors track a patient through the medical system, they are able to look at patient education in a much more specific way to make sure patients get education appropriate to their needs every step of the way, explains Ordelt.

In the past, patient education was a separate session and patient education managers could highlight their policies, special programs, and patient education resources, says BJ Wingert, RN, BSN, MS, a patient education specialist with OhioHealth in Columbus. Now, the survey process for patient education is primarily on the unit during tracers. The bedside nurse and patient care staff need to be able to speak to the patient education resources, follow the policy, and document patient education provided, she explains.

How are patient education managers making sure their health care institution is in continuous compliance with Joint Commission standards for patient education?

"Strategies to prepare are focused on preparing the patient care staff. We have done this in many different ways, such as prep cards, internet printable resources, and sample questions and answers," says Wingert. (See a list of steps Wingert uses in preparation process.)

At Northwestern Memorial Hospital in Chicago, a matrix flowchart is used to track compliance with all standards including patient education. The matrix includes the standard, the key elements of performance, and where the evidence of compliance is found, says Magdalyn Patyk, MS, RN, BC, patient education program manager.

For example, Joint Commission standard PC.6.10 requires that the patient receives education and training specific to his or her needs and care, treatment, and the services provided.

The first element of performance on the matrix is: "Does the patient receive education appropriate to his or her needs?" Evidence of compliance is listed as: "NMH education resources, brochures, videos."

The matrix also has a section to track compliance in each standard. Using the tracer methodology, teams responsible for Joint Commission readiness determine compliance for all categories of standards

Taking personal responsibility

Chart audits at Children's Healthcare of Atlanta are a team effort completed by the Quality and Patient Safety Council. The results are reported on a monthly basis and Ordelt is responsible for looking at the reports to determine what needs to be done to improve patient education. If staff members do not understand a key element of patient education, Ordelt would provide the teaching on the issue. However, if staff are aware of a process or policy and are not compliant, then the manager would take steps to improve compliance.

For survey readiness, steps for preparation process

In order to maintain a constant state of readiness for Joint Commission surveyors to review the patient education process, BJ Wingert, RN, BSN, MS, a patient education specialist with Ohio Health in Columbus, has set in place steps that keep staff members prepared.

They include the following:

  • Keep abreast of changes in the patient education standards.
  • Update and communicate policy changes as needed.
  • Update and communicate documentation issues, data, and form changes.
  • Provide and update resources as needed to meet the needs of our patients.
  • Participate in regulatory team meetings, complete internal assessments, maintain action plans, and provide data as a chapter owner for patient education standards.
  • Prep cards — Prep cards are made for various employees, such as what a patient care staff member needs to know, manager preparations, human resources and employee file preparations, unit preparations, etc.
  • Internet printable resources — Documents are loaded onto the intranet for staff to have access to 24/7. Some documents are set up to be accessed by chapter owners and leadership only.
  • Sample questions and answers for all the chapter standards — Each chapter owner creates question/answer cards for their chapter. The questions are formatted in a way that surveyors might ask the question and correct ways to answer are included. These cards are collated into cards on a ring. Copies are provided to each unit. The content is also loaded onto the intranet for anyone to access.

Ordelt is a member of the Continual Accreditation Readiness Team (CART) that meets monthly. This team looks at new standards and new national patient safety goals and determines how to meet them. They also determine who would be responsible for a particular standard or safety goal.

"As a member of this team, I hear the big picture and learn how patient education fits in if appropriate," says Ordelt.

In addition, Ordelt has regular communication with the two directors in charge of The Joint Commission patient care chapter where most of the patient education standards are located. They let her know when there are compliance problems in patient education that need to be addressed.

Also in place is an interdisciplinary patient and family education Joint Commission team that meets quarterly to determine how to address specific standards. Ordelt works with this team to fix problems and reports progress to the directors in charge of The Joint Commission patient care chapter. This information is also given to the CART team.

According to Wingert the easy part of preparedness is keeping the policies, documentation system, and employee resources current and continuously ready. The challenging part is to get the information to all the employees in each department and on all shifts so that they are able to speak to the standards and resources.

To update staff members at Northwestern Memorial Hospital on what are considered "hot topics" with The Joint Commission, updates are issued via e-mail.

The process of readiness requires continual staff education about patient education, says Ordelt — a reminder that staff need to be doing the learning needs assessment, evaluating learning, and documenting the education process.

It is continual education that keeps staff prepared so they are not taken aback when The Joint Commission survey team shows up, she adds.