Survey Readiness Overview: Failing to Prepare is Preparing to Fail

1. Survey Readiness Overview: Failing to Prepare is Preparing to Fail Donna Wood, RN, Practice Leader, Clinical Operations Chris Martorella, RN, Manager, Clinical Operations

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4. Donna Wood, RN, BSN, MHA, MRMPractice Leader, Clinical Operations As leader of QHR’s Clinical Operations consulting practice, Donna Wood oversees the development and execution of strategies for hospitals and health systems that guide improvement initiatives in Clinical Operations, Care Coordination, Patient Safety, Nursing Excellence, Performance Improvement, and Regulatory Compliance. With more than 30 years of healthcare experience, Donna effectively delivers quality turnaround engagements and clinical transformation strategies to her clients. Prior to joining QHR, she served in various leadership and hospital consulting roles, including: clinical experience in Critical Care at Brigham & Women’s Hospital in Boston, from staff nurse to VP of Critical Care Services and director in Deloitte Consulting’s Healthcare Practice, with a focus on Performance Improvement. A pioneer in Patient Safety, Donna has participated on several Institute for Healthcare Improvement (IHI) teams, including serving as faculty for IHI courses. She was also an early participant in the AHA Patient Safety Fellowship program.

5. Christopher Martorella, MSN, RN, NEA-BC, CENPManager, Clinical Operations Christopher Martorella firmly believes that success in Patient Services is founded on educated and mutually supportive nursing/medical teams, and an ongoing commitment to identifying and resolving root causes of patient dissatisfaction. To this end, much of his work focuses on creating, implementing and evaluating programs that increase competencies and drive quality measures; patient, physician and employee satisfaction; and profitability. Chris brings more than 25 years of healthcare management experience to QHR and its hospital clients. development. With a background in Critical Care Nursing, he has worked in community hospital and academic medical centers and has served as staff nurse through Vice President and Chief Nursing Officer. Double boarded in nursing administration, Chris received his BSN from Florida State University, an MSN from the University of Florida and is currently enrolled in the DNP program at the University of Central Florida.

6. Greetings and Introductions

7. Get Familiar with the Survey Process • Obtain a sample of a typical survey agenda (available on your TJC extranet site) • Review the various activities • Patient care tracers, system tracers, document review, daily briefings and surveyor planning • Familiarize yourself with the standards that will be covered during the focused sessions and tracers as well as the duration of each session • Use your resources (account execs, hospital association) Survey Process

8. Staying Educated • Subscribe to regulatory newsletters and bulletins from the Joint Commission • The Source • EC News • Perspectives • Share information with leaders and staff that are impacted • Participate in webinars and conferences aimed at keeping facilities updated on standards

9. Making Regulatory Fun! • Develop an annual Joint Commission fair • Encourage participation with prizes • Develop fun educational activities • Create a “patient room of horrors” with multiple safety issues and see how many issues staff can identify • Crossword puzzles, word finds and quizzes designed to impart regulatory information • Various booths with critical standard manned by leadership • Plan fun activities for Patient Safety Week as well (another venue to reinforce regulations)

10. Keep Policy Manuals Up To Date • Update policies as regulatory standards change • Assure that appropriate staff are educated to the changes in policy • Keep rosters of staff attendance • Build policies that are multidisciplinary in nature with teams from each area impacted • Example: Plan for the provision of care 2012 2012 2012 2012 2012 2012 2012

11. Making It Easier on Survey Day • Maintain Joint Commission readiness manuals • Key policies that the survey team will want to review prior to starting tracer activities • Supportive documentation should also be contained in these manuals • Remember this information will serve as the “first impression” that the survey team develops about your organization 1 first mpressions

12. Maintaining PI Teams • Assure that Performance Improvement teams are making progress • Use the facility’s overall quality monitoring committee to charter and monitor the progress of teams aimed at improving regulatory compliance • Consider dividing up chapters with different leaders across the organization • Allow them to choose team members • Include front line staff

13. Keep Readiness Activities Robust • Environment of Care rounds • Not just for Plant Ops and Housekeeping staff • This is a great multidisciplinary vehicle for assessing multiple standards • EOC • Life Safety • Infection Control and Prevention • Clinical standards • Include Infection Control, departmental leaders of the areas being surveyed and include staff!

14. Patient Level Readiness • Nursing, case management and the other clinical disciplines should be meeting to review patients for length of stay (LOS) and discharge planning • Consider adding utilization functions • Include pharmacy, dietary, therapy, respiratory and chaplaincy • Frequency of meetings should be based on average LOS • Document meeting results and changes in care plan in the medical record

15. Hourly Rounding • Nursing should be conducting hourly rounding • Evaluate for 4 Ps • Associated with decreases in • Falls and pressure ulcers (hospital acquired conditions) • Call lights for bathroom and pain (increases patient satisfaction)

16. Patient Rounding • At the minimum by nursing leadership but senior leadership involvement is preferred • Learn about issues that are of concern to your customers (patients) • Monitor for regulatory issues • Opportunity for recognizing staff

17. Mock Tracer Activities • Multidisciplinary • Cover as many standards as possible • Use checklists to follow up on issues • All shifts • All departments • On a monthly basis • Involve staff by asking key questions • Remember: second generation tracers!

18. Don’t Forget Patient Safety! • Patient safety goals should also be included in the mock tracer activities • “Hanging out” in the nursing station is a great way to evaluate hand-offs between disciplines and communication between caregivers • What is your process for critical lab value communication? • Monitor medication passes for patient identification and hand washing

19. More on Patient Safety • Pay careful attention to non-surgical settings (Radiology, Special Procedures, med/surg) for compliance to: • Labeling of medications and syringes during procedures • Completion and documentation of time out • Must demonstrate similar standards of care throughout the organization • Go to the pharmacy and ask nursing to open the medication cabinets. How are LASA and high risk medications handled? Policy posted?

20. Conditions of Participation • Don’t forget about monitoring to make sure you are meeting the A-B-Cs of COPs • Have you notified TJC of any new services? • Have you added any off site departments that should be included in the survey process? • Has there been a change in the CEO?

21. Annual Review • Perform a review of all standards and how the hospital meets or exceeds the requirements • Remember to include each element of performance

22. Keep Information in Front of Staff • Post survey readiness information • Posters in patient care areas • Bulletin boards • Streaming television • Electronic bulletin boards • Pay check stuffers • Laminated cards to attach to ID badges • Cafeteria table tents

23. Transparency • Information about compliance rates and performance improvement • Wave of the future • Foster a spirit of competition which may positively impact compliance • Assists staff in being able to speak to quality and performance improvement when questioned by surveyors

24. Consider Survey Complexity • If complex, your facility may surveyed under multiple accreditation programs and standards • Examples: Acute Care, Homecare, Long Term Care, Behavioral Health • Prepare a document that cross references each set of accreditation programs • Include the name of main contact and phone number for each of the programs • Note: The regulatory leader cannot be everywhere at once

25. Prepare Staff for Survey Complexity • Staff and leaders should have access to the current standards in their accreditation manuals • Some support departments (i.e. Therapy Services and Pharmacy) will participate across one or more accreditation standards

26. Watching and Waiting… • With rare exceptions, surveys will be unannounced • Stay in touch with local colleagues to gain insight into surveyor patterns (i.e. State surveyors) • Designate a staff member to check the TJC website daily • CONSTANT survey readiness is key

27. Plan for the Arrival Process • Develop a procedure that outlines what should be done and by whom when surveyors arrive • Staff at hospital entry points should be fully competent on this process • Who do they contact first, second, third? • Provide office extensions and cell phone numbers (with second and third back-ups) • Assure that surveyors are positively identified (picture IDs) • Notification of the rest of the hospital • Drill this process

28. Readiness Guide

29. References Survey Activity Guide for Health Care Organizations (2012). The Joint Commission. Accessed from the web on March 15, 2012: www.tjc.org

31. Upcoming CSR Webinars Upcoming Programs • IT Workflow: Getting Nurses Back to Patients April 24, 2012 2:00 p.m. CST • CSR webinar: Emergency Preparedness – Contingency Planning for Whatever Happens May 16, 2012 11:00 a.m. CST • CSR webinar: New Joint Commission Standards (Clinical and Environment of Care) July 18, 2012 11:00 a.m. CST • CSR webinar: Be Prepared to Meeting National Patient Safety Goals September 19, 2012 11:00 a.m. CST • CSR webinar: Environment of Care – Issues You Should Plan to Avoid November 14, 2012 11:00 a.m. CST Register at www.QHRLearningInstitute.com

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34. Thanks for Attending! Intended for internal guidance only, and not as recommendations for specific situations. Readers should consult a qualified attorney for specific legal guidance.